International

Textbook of
Aesthetic Surgery

Nicolò Scuderi
Bryant A. Toth
Editors

123
International Textbook of Aesthetic Surgery
Nicolò Scuderi • Bryant A. Toth
Editors

International Textbook
of Aesthetic Surgery
Editors
Nicolò Scuderi Bryant A. Toth
Department of Plastic Surgery Private Practice
University of Rome Toth Plastic Surgery
Rome San Francisco, CA
Italy USA
Clinical Professor of Surgery
University of California
San Francisco, CA
USA

Illustrators
William Winn, USA
Levent Efe, Australia
Elisa Botton, Italia
Antonia Conti, Italia

Revised translation from the Italian language edition: Trattato Internazionale di Chirurgia Estetica; Copyright © 2012
Verducci Editore - Roma. All Rights Reserved.
This English edition of Trattato Internazionale di Chirurgica Estetica by Nicolò Scuderi and Bryant A. Toth is
published by Springer International Publishing AG Switzerland by arrangement with Verduci Editore s.r.l.

ISBN 978-3-662-46598-1 ISBN 978-3-662-46599-8 (eBook)

DOI 10.1007/978-3-662-46599-8

Library of Congress Control Number: 2016939018

© Springer Berlin Heidelberg 2016

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Introduction

This textbook represents the collaboration of two close friends from separate continents who
felt there was a need for a true International Textbook of Aesthetic Surgery. Such an idea is not
a new one. Italian and American plastic surgeons have been meeting on a biannual basis shar-
ing ideas as well as formulating new ones. At our first meeting in 1988, it was a surprise for
both of us that although we agreed most of the time, frequently different approaches led to
similarly satisfactory results. These meetings became a forum for presenting new ideas as well
as novel surgical techniques. Included in this book are many who participated in these collabo-
rations as well as their pupils. We used this as a starting point to transfer this experience into a
book form in order to share with others what we think represents aesthetic surgery today.
Surgery has changed dramatically over the past 20 years, and nowhere is that more evident
than in cosmetic surgery. Expectation is high and the relationship between plastic surgeons and
patients has become almost a commodity with a seller and a buyer. Today’s patient is unwilling
to accept long hospitalizations, lengthy periods of recovery, or unattractive scarring. The
expectation of a “natural look” post surgery is now the cornerstone of modern aesthetic sur-
gery. The role of nonsurgical treatments for the skin, i.e., fillers, Botox®, and the like has
complemented what we are able to do surgically.
In this textbook, we present a panorama of surgical techniques and share with you what we
consider contemporary aesthetic surgery to be. And it is in this vein that the intent of this book
is not to present an encyclopedia of surgical techniques but rather an approach from those who
we feel are on the cutting edge, both medically and surgically. As you can note from the index
we have invited not only Italian and American authors but trusted friends whose work and
approach we admire.
Since the Italian publication of this book, we have lost two shining stars in our world of
aesthetic surgery, Dr. Fernando Ortiz-Monasterio and Dr. Daniel Marchac. Their two chapters,
the first two of the book, lay the cornerstone for this publication and also represent their last
contributions to the literature. We all owe a great debt to them for their innovations, skill, and
their willingness to be mentors and teachers to many of us.
We would like to thank all of those who have contributed to this project including our fami-
lies, office staff, and fellow authors. Most importantly, we would like to thank our patients who
have provided the surgical challenges as well as the continual inspiration we have enjoyed as
plastic surgeons.

Nicolo Scuderi and Bryant Toth

v
Contents

Part I Introduction to Aesthetic Surgery

The Concept of Beauty in Different Cultures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Fernando Ortiz Monasterio
Is There a Frontier Between Aesthetic and Reconstructive Surgery? . . . . . . . . . . . . . . 17
Daniel Marchac
Indications, Psychological Issues and Selection of Patients in Aesthetic Surgery. . . . . 27
Nicolò Scuderi, Bryant A. Toth, Stephen P. Daane, and Diego Ribuffo
How to Manage an Aesthetic Surgery Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Karen Evind
Photography in Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Maurizio Valeriani and Francesco S. Madonna Terracina
Anaesthesia in Cosmetic Surgery: European Prospective . . . . . . . . . . . . . . . . . . . . . . . 63
Pierangelo Di Marco, Gianni Sampietro, and Riccardo Bellucci
Anesthesia for the Cosmetic Patient: An American Perspective. . . . . . . . . . . . . . . . . . . 75
A. Roderick Forbes
Post-operative Pain Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Gabriele Finco, Gian Nicola Aru, and Mario Musu
The American Legal System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Neal R. Reisman, Gerald F. Kaplan, and Steven M. Gonzalez

Part II The Breast

History of Aesthetic Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Thomas M. Biggs
Augmentation Mastoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Andrea Grisotti, Massimo Callegari, and Domenico De Fazio
Cosmetic Breast Augmentation with Fat Grafting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Daniel Del Vecchio and Roger Khouri
Mastopexy Without Implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Louis Benelli, Michele Pascone, and Charles Benelli
Mastopexy with Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Francesco Stagno D’Alcontres, Flavia Lupo, Gabriele Delia,
and Michele R. Colonna
Secondary Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Pietro Berrino

vii
viii Contents

Inverted-T Scar Reduction Mammoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Michele Pascone and Andrea Armenio
Vertical Breast Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Diego Ribuffo, Matteo Atzeni, and Francesco Serratore
Gigantomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Francesco Moschella, Adriana Cordova, and Francesca Toia
Aesthetic Surgery for Breast Asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
L. Franklyn Elliott and J. Nicolas Mclean
Tuberous Breast: Different Morphological Types and Corresponding
Correction Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Egle Muti
Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Carlo Cavina
Reoperative Aesthetic Breast Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
James C. Grotting and Michael S. Hanemann Jr.

Part III Trunk and Extremities

History of Aesthetic Surgery of the Trunk and the Extremities . . . . . . . . . . . . . . . . . . 315

Giovanni Di Benedetto, Davide Talevi, Luca Grassetti, and Aldo Bertani
Aesthetic Abdominoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Carlo D’Aniello and Giuseppe Nisi
Evolution of Lipoplasty Then, Now, and the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
Peter B. Fodor
Tridimensional Liposculpture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Marco Gasparotti and Paolo Iannitelli
Lipoabdominoplasty: Saldanha’s Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Osvaldo R. Saldanha, Sérgio F.D. Azevedo, Octávio A.L. Luz,
Osvaldo R. Saldanha Filho, and Cristianna B. Saldanha
Lipofilling and Correction of Postliposuction Deformities . . . . . . . . . . . . . . . . . . . . . . 387
K. Ning Chang
Plastic Surgery in Massive Weight Loss Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409
Dennis J. Hurwitz and Siamak Agha-Mohammadi
Brachioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Richard J. Zienowicz and Erik A. Hoy
Hand Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Cristina Spalvieri and Francesco Brunelli
Medial Dermolipectomy of the Thigh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Flavio Saccomanno
Gluteoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Constantino Mendieta
Male Genital Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Giovanni Alei, Piero Letizia, and Lavinia Alei
Aesthetic Surgery of the Female Genitalia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Malcolm A. Lesavoy and Catherine Huang Begovic
Ancillary Nonsurgical Treatments: Trunk and Abdomen . . . . . . . . . . . . . . . . . . . . . . . 515
David S. Chang
Contents ix

Part IV The Scalp

General Concepts and Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525

Marco Toscani and Mariangela Ciotti
Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539
Marco Toscani and Mariangela Ciotti
Scalp Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Martin G. Unger and Marco Toscani
Skin Extenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Ciro De Sio and Marco Toscani
The Suture of Nordstrom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Manfredi Greco, Tiziana Vitagliano, and Rolf E.A. Nordstrom

Part V The Nose

Historical Overview of Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585

Carmine Alfano and Salvatore Di Cristo
Basic Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Carmine Alfano, Stefania Tenna, Virginia Ciaravolo, Antonio Rusciani,
and Stefano Chiummariello
Septoplasty and Treatment of Turbinate Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . 625
Andrea Gallo, Giulio Pagliuca, and Salvatore Martellucci
Full- and Semi-open Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635
H. Holmstrom
Secondary Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Ronald P. Gruber, Kamakshi Zeidler, and Drew Davis
Rhinoplasty in Patients with Malformations of the Head and Neck . . . . . . . . . . . . . . 669
Gian Vittorio Campus, Carmine Alfano, and Federico De Gado
The Twisted Nose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 687
Wolfgang Gubisch and J. Eichhorn-Sens
Profiloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701
Carlo Cavina

Part VI The Eyelids

History of Cosmetic Eyelid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721

Isabella C. Mazzola
Anatomy of the Orbitopalpebral Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
Paolo Persichetti, Stefania Tenna, and Annalisa Cogliandro
Upper Eyelid Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
Bryant A. Toth and Stephen P. Daane
Asian Upper Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Hop Le
Lower Eyelid Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761
Kristin A. Boehm and Foad Nahai
Blepharoplasty: Minimally Invasive Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773
Nicolò Scuderi and Luca A. Dessy
x Contents

Lateral Canthal Surgery in Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 783

Glenn W. Jelks and Elizabeth B. Jelks
Complications of Aesthetic Blepharoplasty and Revisional Surgeries . . . . . . . . . . . . . 799
Richard D. Lisman and Christopher I. Zoumalan

Part VII The Ear

Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 821
Corrado Rubino, Francesco Farace, and Pietro Mulas

Part VIII The Face: Surgical Treatment

History of Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841

Riccardo F. Mazzola and Isabella C. Mazzola
The Aging Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
Bryan C. Mendelson and Justin X. O’Brien
Forehead and Brow Rejuvenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
Erik A. Hoy, Benjamin Z. Phillips, and Patrick K. Sullivan
Suspension Techniques in Aesthetic Surgery of the Face . . . . . . . . . . . . . . . . . . . . . . . 875
Ithamar Stocchero
Rejuvenation of the Midface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889
Brunno Ristow
The Minimal Access Cranial Suspension (MACS) Lift . . . . . . . . . . . . . . . . . . . . . . . . . 901
Marco Mazzocchi and Nicolò Scuderi
The Suprazygomatic (High SMAS) Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
Bryant A. Toth
Surgical Treatment of Ageing in the Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 921
Mario Pelle Ceravolo
Reoperative Surgery of the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 961
Bruce F. Connell and Michael J. Sundine
Suspension Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 973
Franco R. Perego
3D Facial Volumization with Anatomic Alloplastic Implants . . . . . . . . . . . . . . . . . . . . 985
Edward O. Terino
Facial Lipofilling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031
Domenico De Fazio and Laura Barberi
Cheiloplastics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1047
Flavio Saccomanno

Part IX The Face: Non-surgical Treatment

Botulinum Toxin: BOTOX® . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1073

Ina A. Nevdakh, Bryant A. Toth, and Stephen P. Daane
Filler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083
M. Greco, T. Vitagliano, and A. Greto Ciriaco
Chemical Peel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1095
A. Tedeschi, D. Massimino, G. Fabbrocini, and G. Micali
Contents xi

Advances in Facial Plastic Rejuvenation with Ablative Laser Technology:

Can Clinical Results Be Tailored Based on Histology Effects?. . . . . . . . . . . . . . . . . . 1105
Mario A. Trelles
Laser Resurfacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1113
Franco R. Perego
Intense Pulsed Light Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1123
M.G. Onesti and P. Fioramonti
Lasers and Intense Light Systems as Adjunctive Techniques
in Functional and Aesthetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133
Mario A. Trelles
Noninvasive Physical Treatments in Facial Rejuvenation . . . . . . . . . . . . . . . . . . . . . . 1155
Luca A. Dessy
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion . . . . . 1167
Nevena Skroza, Ilaria Proietti, Concetta Potenza, and Luca A. Dessy
Antiaging Cosmeceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1183
Lily Talakoub, Isaac M. Neuhaus, and Siegrid S. Yu

Part X The Future

Preventive Medicine and Healthy Longevity: Basis for Sustainable

Anti-Aging Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1213
Giovanni Scapagnini, Calogero Caruso, and Giovanni Spera
Anti-Aging: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1229
Alfred P. Yoon, Stephen P. Daane, Bryant A. Toth, and Ina A. Nevdakh
Aesthetic Regenerative Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1239
Claudio Calabrese, Tulc Tiryaki, N. Findikli, and D. Tiryaki

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253
Contributors

Siamak Agha-Mohammadi, BSc, MB BChir, PhD, FACS University of Pittsburgh

Medical School, Pittsburgh, PA, USA
Giovanni Alei, MD Professore Associato di Urologia, Dipartimento di Chirurgia,
Università di Roma “Sapienza”, Rome, Italy
Lavinia Alei, MD Dipartimento di Dermatologia, Università di Roma “Sapienza”,
Rome, Italy
Carmine Alfano, MD Dipartimento di Scienze Chirurgiche, Università di Perugia,
Perugia, Italy
Andrea Armenio, MD U.O.C. di Chirurgia Plastica e Ricostruttiva Universitaria,
Azienda Ospedaliero-Universitaria Policlinico di Bari, Bari, Italy
Gian Nicola Aru, MD Cattedra di Anestesia, Dipartimento di Scienze Mediche
“M. Aresu”, Università di Cagliari, Cagliari, Italy
Matteo Atzeni, MD Unità di Chirurgia Plastica, Dipartimento di Chirurgia,
Università di Cagliari, Cagliari, Italy
Sérgio F.D. Azevedo, MD Department of the Plastic Surgery, Santa Cecília
University, Santos, São Paulo, Brazil
Laura Barberi, MD Chirurgia Plastica e Ricostruttiva, Università di Siena, Siena, Italy
Riccardo Bellucci, MD Dipartimento di Anestesia e Rianimazione, Polo
Ospedaliero Rivoli, ASL Torino 3, Turin, Italy
Charles Benelli, MD Plastic Reconstructive & Aesthetic Surgery, Hôpital
Privé d’Athis Mons, Athis Mons, France
Louis Benelli, MD Plastic Reconstructive & Aesthetic Surgery, Hôpital
Privé d’Athis Mons, Athis Mons, France
Pietro Berrino, MD Private Practice, Chirurgia Plastica Genova S.r.l., Genoa, Italy
Aldo Bertani, MD, PhD Professore Ordinario di Chirurgia Plastica, Dipartimento di
Scienze Mediche e Chirurgiche, Università Politecnica delle Marche, Ancona, Italy
Thomas M. Biggs, MD Baylor University College of Medicine, Houston, TX, USA
Kristin A. Boehm, MD Private Practice, Paces Plastic Surgery, Atlanta, GA, USA
Francesco Brunelli, MD Institut de la Main, Paris, France
Claudio Calabrese, MD U.O.S. di Chirurgia Oncologica e Rigenerativa, Breast Unit,
Azienda Ospedaliero Universitaria Careggi, Florence, Italy
Massimo Callegari, MD Private Practice, Milan, Italy

xiii
xiv Contributors

Gian Vittorio Campus, MD Professore Ordinario di Chirurgia Plastica, Dipartimento

di Dermatologia, Università di Sassari, Sassari, Italy
Calogero Caruso MD Unità di Immunosenescenza, Dipartimento di Patobiologia e
Metodologie Biomediche, Università di Palermo, Palermo, Italy
Carlo Cavina, MD Dipartimento di Scienze Chirurgiche Specialistiche,
Anestesiologiche, Università di Bologna, Bologna, Italy
David S. Chang, MD, FACS Private Practice, San Francisco, CA, USA
K. Ning Chang, MD Private Practice, California Pacific Medical Center,
San Francisco, CA, USA
Stefano Chiummariello, MD, PhD U.O.C. di Chirurgia Plastica, Dipartimento
di Scienze Chirurgiche, Università di Perugia, Perugia, Italy
Virginia Ciaravolo Psicologa, Chirurgia Plastica e Ricostruttiva, Università
di Roma “Sapienza”, Rome, Italy
Mariangela Ciotti, MD U.O.C. di Chirurgia Plastica, Università di Roma
“Sapienza”, Rome, Italy
Annalisa Cogliandro, MD U.O.C. di Chirurgia Plastica, Università
“Campus Bio-Medico”, Rome, Italy
Michele R. Colonna, MD Professore Associato di Chirurgia Plastica, Dipartimento
di Specialità Chirurgiche, Università di, Messina, Azienda Ospedaliera Universitaria
“G. Martino”, Messina, Italy
Bruce F. Connell, MD Private Practice Plastic Surgery, Santa Ana, CA, USA
Adriana Cordova, MD Sezione di Chirurgia Plastica e Ricostruttiva, Dipartimento
di Discipline Chirurgiche e Oncologiche, Università di Palermo, Palermo, Italy
Ernesto d’Aloja, MD Professore Ordinario di Medicina Legale, Dipartimento
di Scienze Giuridiche e Forensi, Università di Cagliari, Cagliari, Italy
Carlo D’Aniello, MD Professore Ordinario di Chirurgia Plastica, Dipartimento
di Chirurgia, Università di Siena, Siena, Italy
Stephen P. Daane, MD Private Practice, San Francisco and San Ramon, CA, USA
Drew Davis, MD Department of Plastic and Reconstructive Surgery, Santa Clara Valley
Medical Center, San Jose, CA, USA
Domenico De Fazio, MD Divisione di Chiurgia Plastica, Clinica San Pio X, Milan, Italy
Federico De Gado, MD, PhD Private Practice, Rome, Italy
Ciro De Sio, MD U.O.C. di Chirurgia Plastica, Istituto Dermopatico
dell’Immacolata (IDI), Rome, Italy
Daniel Del Vecchio, MD MBA Private Practice, Boston Back Bay Plastic Surgery,
Boston, MA, USA
Gabriele Delia, MD Ricercatore Universitario di Chirurgia Plastica, Dipartimento
di Specialità Chirurgiche, Università, di Messina, Azienda Ospedaliera Universitaria
“G. Martino”, Messina, Italy
Luca A. Dessy, MD Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
Contributors xv

Giovanni Di Benedetto, MD, PhD Professore Associato di Chirurgia Plastica,

Dipartimento di Scienze Mediche e Chirurgiche, Università Politecnica delle Marche,
Ancona, Italy
Salvatore Di Cristo, MD Private Practice, Naples, Italy
Pierangelo Di Marco, MD Dipartimento di Scienze Anestesiologiche, Medicina
Critica e Terapia del Dolore, Università di Roma “Sapienza”, Rome, Italy
J. Eichhorn-Sens, MD Department of Facial Plastic Surgery, Marienhospital
Stuttgart, Stuttgart, Germany
L. Franklyn Elliott, MD Atlanta Plastic Surgery, Emory University Partner,
Atlanta, GA, USA
Karen Evind Toth Plastic Surgery, San Francisco, CA, USA
Gabriella Fabbrocini, MD Dipartimento di Patologia Sistematica, Sezione
di Dermatologia, Università di Napoli Federico II, Naples, Italy
Francesco Farace, MD Dipartimento di Scienze Chirurgiche, Microchirurgiche
e Mediche, Università di Sassari, Sassari, Italy
Gabriele Finco, MD Dipartimento di Scienze Mediche “M. Aresu”, Università
di Cagliari, Cagliari, Italy
N. Findikli, MD Department of Tissue Engineering, Yildiz Technical University,
Istanbul, Turkey
Paolo Fioramonti, MD U.O.C. di Chirurgia Plastica e Ricostruttiva,
Università di Roma “Sapienza”, Rome, Italy
Peter B. Fodor, MD Private Practice, Santa Monica, CA, USA
A. Roderick Forbes, MBChB, FFARCS Department of Anesthesia, California Pacific
Medical Center, San Francisco, CA, USA
Andrea Gallo, MD, Ph.D Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche,
Università di Roma “Sapienza”, Rome, Italy
Marco Gasparotti, MD Chirurgia Plastica, Università di Camerino, Camerino, Italy
Steven M. Gonzalez, JD Steven M Gonzalez & Associates PC, Attorneys at Law,
McAllen, TX, USA
Luca Grassetti, MD Dipartimento di Chirurgia Plastica, Ricostruttiva ed Estetica,
Università Politecnica delle Marche, Ancona, Italy
Manfredi Greco, MD Dipartimento di Medicina Sperimentale e Clinica,
Università “Magna Graecia” di Catanzaro, Catanzaro, Italia
Antonio Greto Ciriaco, MD U.O.C. di Chirurgia Plastica, Ricostruttiva ed Estetica,
Università “Magna Graecia” di Catanzaro, Catanzaro, Italy
Andrea Grisotti, MD Responsabile Unità di Chirurgia Plastica, Divisione di Chiurgia
Plastica, Clinica San Pio X, Milan, Italy
James C. Grotting, MD, FACS Private Practice, Grotting Plastic Surgery,
Birmingham, AL, USA
Ronald P. Gruber, MD Stanford University, Palo Alto, CA, USA
xvi Contributors

Wolfgang Gubisch, MD, Department of Facial Plastic Surgery, Marienhospital

Stuttgart, Stuttgart, Germany
Michael S. Hanemann, Jr., MD Private Practice, Hanemann Plastic Surgery,
Baton Rouge, LA, USA
Hans Holmstrom, MD Sahlgrenska University Hospital, Gothenburg, Sweden
Erik A. Hoy, MD Department of Plastic Surgery, Alpert Medical School
of Brown University, Providence, RI, USA
Catherine Huang Begovic, MD, FACS Private Practice, Beverly Hills, CA, USA
Dennis J. Hurwitz, MD, FACS University of Pittsburgh Medical School,
Pittsburgh, PA, USA
Paolo Iannitelli, M.D. Chirurgia Generale, Rome, Italy
Elizabeth B. Jelks, MD Private Practice Ophthalmology, New York, NY, USA
Glenn W. Jelks, MS, MD, FACS Ophthalmology and Plastic Surgery, New York
University Langone Medical Center, New York, NY, USA
Gerald F. Kaplan, MD, JD Attorney at Law, Philadelphia, PA, USA
Roger Khouri, MD, FACS Private Practice, Miami Breast Center, Miami, FL, USA
Hop Le, MD, FACS Department of Plastic Surgery, Kaiser Foundation Hospital,
San Rafael, CA, USA
Malcolm A. Lesavoy, MD, FACS Private Practice, Encino, CA, USA
Piero Letizia, MD Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
Richard D. Lisman, MD, FACS Division of Ophthalmic Plastic and Reconstructive
Surgery, Department of Ophthalmology, New York University School of Medicine,
New York, NY, USA
Flavia Lupo, MD Chirurgia Plastica, Dipartimento di Specialità Chirurgiche,
Università di Messina, Azienda Ospedaliera Universitaria “G. Martino”, Messina, Italy
Octávio A.L. Luz, MD Department of the Plastic Surgery, Santa Cecília University,
Santos, São Paulo, Brazil
Francesco S Madonna Terracina, MD U.O.C. di Chirurgia Plastica, Ospedale
“San Filippo” Neri, Rome, Italy
Daniel Marchac, MD Craniofacial Unit, Hopital Necker Enfants Malades,
Surgical Office, Paris, France
Salvatore Martellucci, MD U.O.C. di Otorinolaringoiatria, Dipartimento
di Scienze e Biotecnologie Medico-Chirurgiche, Università di Roma “Sapienza”,
Rome, Italy
Doriana Massimino, MD U.O.C. di Clinica Dermatologica, Università di Catania,
Catania, Italy
Marco Mazzocchi, MD, PhD Dipartimento di Scienze Chirurgiche, Radiologiche
ed Odontostomatologiche, Università di Perugia, Perugia, Italy
Isabella C. Mazzola, M.D. Klinik für Plastische und Ästhetische Chirurgie,
Klinikum Landkreis Erding, Erding, Germany
Contributors xvii

Ricardo F. Mazzola, M.D. Department of Clinical Sciences and Community Health,

Fondazione IRCCS Ca’ Granda. Ospedale Maggiore Policlinico, Milano, Italy
J. Nicolas Mclean, MD Private Practice, Conyers, GA, USA
Bryan C. Mendelson, FRCSE, FRACS, FACS The Centre for Facial Plastic Surgery,
Melbourne, VIC, Australia
Constantino Mendieta, MD, FACS Private Practice, Miami, FL, USA
Giuseppe Micali, MD Dipartimento di Specialità Medico-Chirurgiche, Università
di Catania, Catania, Italy
Francesco Moschella, MD Dipartimento di Discipline Chirurgiche e Oncologiche,
Università di Palermo, Palermo, Italy
Pietro Mulas, MD U.O.C. di Chirurgia Plastica, Dipartimento di Scienze Chirurgiche,
Microchirurgiche e Mediche, Università di Sassari, Sassari, Italy
Mima Müller MD Dipartimento di Scienze Giuridiche e Forensi, Università di Cagliari,
Cagliari, Italy
Mario Musu, MD Dipartimento di Scienze Mediche “M. Aresu”, Ricercatore
Universitario di Anestesiologia, Università di Cagliari Cagliari, Cagliari, Italy
Egle Muti, MD Professore Associato di Chirurgia Plastica, Dipartimento
di Scienze Cliniche e Biologiche, Università di Torino, Turin, Italy
Foad Nahai, MD Paces Plastic Surgery, Atlanta, GA, USA
Isaac M. Neuhaus, MD Department of Dermatology, University of California,
San Francisco, CA, USA
Ina A. Nevdakh MD Department of Plastic Surgery, Oregon Health Sciences University,
Portland, OR, USA
Giuseppe Nisi, MD Ricercatore Universitario di Chirurgia Plastica, Dipartimento
di Chirurgia, Università di Siena, Siena, Italy
Rolf E.A. Nordstrom, MD, PhD Chief, The Nordstrom Hospital of Plastic Surgery,
Helsinki, Finland
Justine X. O’Brien, MD Taylor Laboratory, Department of Anatomy and Neuroscience,
University of Melbourne, Melbourne, VIC, Australia
Maria Giuseppina Onesti, MD Dipartimento di Chirurgia, Università di Roma
“Sapienza”, Policlinico Umberto I, Rome, Italy
Fernando Ortiz Monasterio, MD Division Of Plastic Surgery, Emeritus School
of Medicine, Hospital General Manuel Gea Gonzalez, Universidad Nacional
Autonoma De Mexico, Mexico City, Mexico
Giulio Pagliuca, MD, Ph.D. U.O.C. di Otorinolaringoiatria, Dipartimento di Scienze e
Biotecnologie Medico-Chirurgiche, Università di Roma “Sapienza”, Rome, Italy
Michele Pascone, MD Dipartimento per le Applicazioni in Chirurgia delle Tecnologie
Innovative, Università di Bari, Bari, Italy
Mario Pelle Ceravolo, MD Docente di Chirurgia Estetica Master Università di Padova,
Padova, Italy
Franco R. Perego, MD Scuola di Specializzazione in Chirurgia Plastica, Università di
Padova, Padova, Italy
xviii Contributors

Paolo Persichetti, MD Dipartimento Centro Integrato di Ricerca (C.I.R.),

Università “Campus Bio-Medico”, Rome, Italy
Benjamin Z. Phillips, MD Department of Plastic Surgery, Brown University,
Rhode Island Hospital, Providence, RI, USA
Concetta Potenza, MD U.O.C. di Dermatologia “Daniele Innocenzi”,
Università di Roma “Sapienza”, “Polo Pontino”, Rome, Italy
Ilaria Proietti, MD U.O.C. di Dermatologia “Daniele Innocenzi”, Università
di Roma “Sapienza”, “Polo Pontino”, Rome, Italy
Neal R. Reisman, MD, JD, FACS Chief of Plastic Surgery, Baylor-St. Luke’s Episcopal
Hospital, Houston, TX, USA
Diego Ribuffo, MD Dipartimento di Scienze Chirurgiche e Odontostomatologiche,
Università di Cagliari, Cagliari, Italy
Francesco Ricottilli, MD Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
Brunno Ristow, MD, FACS Private Practice, California Pacific Medical Center,
San Francisco, CA, USA
Corrado Rubino, MD, FEBOPRAS, Dipartimento di Scienze Chirurgiche,
Microchirurgiche e Mediche, Università di Sassari, Sassari, Italy
Antonio Rusciani, MD, PhD Libero Professionista, Chirurgia Plastica e Ricostruttiva,
Rome, Italy
Flavio Saccomanno, MD Private Practice, Rome, Italy
Cristianna B. Saldanha, MD Department of Plastic Surgery, Santa Cecília University,
Santos, São Paulo, Brazil
Osvaldo R. Saldanha, MD Chairman of Plastic Surgery Department, Santa Cecília
University, Santos, São Paulo, Brazil
Osvaldo R. Saldanha Filho, MD Department of Plastic Surgery, Santa Cecília University,
Santos, São Paulo, Brazil
Gianni Sampietro, MD Dipartimento di Scienze Anestesiologiche, Medicina Critica e
Terapia del Dolore, Università di Roma “Sapienza”, Rome, Italy
Giovanni Scapagnini, MD Dipartimento Di Scienze Della Salute, Università del Molise,
Campobasso, Italy
Nicolò Scuderi, MD Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
Francesco Serratore MD Dipartimento di Chirurgia ‘P.Valdoni’, U.O.C. di Chirurgia
Plastica e Ricostruttiva, Università di Roma “Sapienza”, Rome, Italy
Nevena Skroza, MD Dipartimento di Dermatologia “Daniele Innocenzi”, Università di
Roma “Sapienza”, Rome, Italy
Cristina Spalvieri, MD Dipartimento di Dermatologia e Chirurgia Plastica, Università di
Roma “Sapienza”, Rome, Italy
Giovanni Spera, MD Dipartimento di Fisiopatologia Medica, Università
di Roma “Sapienza”, Rome, Italy
Francesco Stagno d’Alcontres, MD Professore Ordinario di Chirurgia Plastica,
Dipartimento di Specialità Chirurgiche, Università di Messina, Azienda Ospedaliera
Universitaria “G. Martino”, Messina, Italy
Contributors xix

Ithamar Stocchero, MD Head of Plastic Surgery, Centro Médico Viver Melhor, São Paulo,
Brazil
Patrick K. Sullivan, MD Department of Plastic Surgery, Brown University,
Rhode Island Hospital, Providence, RI, USA
Michael J. Sundine, MD, FACS, FAAP Private Practice, Newport Beach, CA, USA
Lily Talakoub, MD Department of Dermatology, University of California, San Francisco,
CA, USA
Davide Talevi, MD Dipartimento di Chirurgia Plastica, Ricostruttiva ed Estetica,
Università Politecnica delle Marche, Ancona, Italy
Aurora Tedeschi, MD U.O.C. di Clinica Dermatologica, Università di Catania,
Catania, Italy
Stefania Tenna, MD, PhD Dipartimento Centro Integrato di Ricerca (C.I.R.),
Università “Campus Bio-Medico”, Rome, Italy
Edward O. Terino, MD Plastic Surgery Institute of Southern California,
Thousand Oaks, CA, USA
D. Tiryaki, MD Department of Byophysics, Yeniyuzyll University, Istanbul, Turkey
Tulc Tiryaki, MD Cellest Plastic Surgery, Levent, Istanbul, Turkey
Francesca Toia, MD Sezione di Chirurgia Plastica e Ricostruttiva, Dipartimento
di Discipline Chirurgiche e Oncologiche, Università di Palermo, Palermo, Italy
Marco Toscani MD Ricercatore Universitario di Chirurgia Plastica, Dipartimento di
Chirurgia, Università di Roma “Sapienza”, Rome, Italy
Bryant A. Toth, MD, FACS Private Practice, Toth Plastic Surgery,
San Francisco, CA, USA
Clinical Professor of Surgery, University of California, San Francisco, CA, USA
Mario A. Trelles, MD Instituto Médico Vilafortuny, Antoni De Gimbernat
Foundation, Cambrils, Spain
Martin G. Unger, MD, FRCSC, ABCS, ABHRS Medical Director, the Unger
Cosmetic Surgery Center, Cosmetic Surgery Lecturer, University of Toronto,
Toronto, ON, Canada
Maurizio Valeriani, MD U.O.C. di Chirurgia Plastica, Ospedale “San Filippo” Neri,
Rome, Italy
Tiziana Vitagliano, MD U.O.C. di Chirurgia Plastica Ricostruttiva ed Estetica,
Fondazione Oncologica “T. Campanella”, Polo Oncologico di Eccellenza
“Germaneto”, Catanzaro, Italy
Alfred P. Yoon, BS Department Bioengineering, Lawrence Berkeley National Laboratory,
Berkeley, CA, USA
Siegrid S. Yu, MD Department of Dermatology, University of California, San Francisco,
CA, USA
Kamakshi Zeidler, MD Private Practice, Zeidler Plastic Surgery, Campbell, CA, USA
Richard J. Zienowicz, MD, FACS Department of Plastic Surgery, Alpert Medical
School of Brown University, Providence, RI, USA
Christopher I. Zoumalan, MD Division of Ophthalmic Plastic and Reconstructive
Surgery, Department of Ophthalmology, New York University School of Medicine,
New York, NY, USA
 Part I
Introduction to Aesthetic Surgery
 The Concept of Beauty in Different
Cultures
Fernando Ortiz Monasterio
The discussion of what is beautiful and what is not has occu-
pied the attention of philosophers, mathematicians, artists,
architects, anatomists, surgeons, and theologians for the last
2,500 years. In general terms the idea of beauty applies to the
human figure, to animals, and other elements of nature as
well as to architecture, design, and artistic representations.
Human representations left by early societies emphasize
anatomical features related to fertility, like the wide hips of
the “Venus” de Lespugue and other examples of primitive art
associated with obesity suggesting good reserves of fat nec-
essary for survival in times of famine. These desirable quali-
ties were obviously considered beautiful and precede the
ideas of Greek philosophers who associated both concepts:
beauty and virtue (Fig. 1).
The representation of feminine figures with wide hips
associated with fertility is present in many cultures as can be
seen in the Cycladic art of 2000 BC and in the deliciously
erotic figures from the preclassic period of Mexico, molded
around 500 BC not only representing fertility but also an aes-
thetic ideal (Fig. 2).
The Greeks had a passion for beauty and explored the
rules for the harmonious proportions applicable to all the
things in nature and in art. The search for a mathematical
formula for beauty was initiated by Pythagoras, who did not
write much but influenced his disciples, including Plato. He
developed the theory of harmony and conceived the essence
of beauty as the order, proportion, and harmony of the sub-
ject. He also considered beauty as a quantitative, mathemati-
cal quality that could be expressed in numbers.
Similar ideas were proposed by Philolao in the fifth cen-
tury BC and further developed by Vitruvio in his book “De
F. Ortiz Monasterio, MD
Division of Plastic Surgery, Emeritus School of Medicine, Hospital
General Manuel Gea Gonzalez, Universidad Nacional Autonoma
De Mexico, Mexico City, Mexico
e-mail: fortizm@prodigy.net.mx
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_1
Architectura” written in the first century AD with detailed
discussions on the proportions of the human body [1].
The return to platonic thinking in relation to beauty
appears in the works of Bonaventura de Bagnoregio
(“Itinerarium mentis in Deum,” XII AC) [2], who wrote that
beauty was implicit in the original design of God at the time
of the creation, and Thomas de Aquino (XII AC), who added
that “beauty is what is pleasant to our eyes” [3].
Greek anatomical knowledge based on keen observation of
the human body (combined with their passion for beauty)
resulted in a magnificent production of sculpture considered to
this day as the aesthetic golden standard. These classical propor-
tions were accepted by the Romans who reproduced many of
the Greek works preserving the canon of beauty later adopted
by the anatomists of the sixteenth century such as Vesalius,
Eustachio, Casserius, Mascagni, and many others who followed
the Greek models for the illustration of their work [4]. For the
validity of this concept we may observe the similarity of the
body of the sculpture of the Greek “Discóbolo” with a modern
Olympic athlete. The main difference between these two mod-
els is conceptual; beauty for the Greeks was the combination of
the body and the soul with a developed intellect whereas physi-
cal beauty only is considered for the modern athlete (Fig. 3).
In his work “Anatomy for Artists” published in 1723,
Genga [5] selected roman copies of classical sculptures of
the late Hellenistic period: the young man in a position of
attack, a thoroughly trained athlete representing the Greek
ideal of harmony of the body and the soul. He also repre-
sented Aphrodite as a serene being, alone in her human
divinity; she is a mature woman with voluptuous curves;
except from the small breasts, she could represent the mod-
ern occidental concept of feminine beauty (Fig. 4).
Many authors during the Renascence maintained the con-
cept of the mathematical formula for beauty. The writings of
Piero della Francesca, Fra Luca Paccioli, and especially of
Dürer contributed to establish an aesthetic canon that had great
influence on the work of many artists like Donatello, della
Robbia, Verochio, Leonardo, Raphaello, and Michelangelo.
3
4 F. Ortiz Monasterio

Fig. 1 Venus de Lespugue. Prehistoric. Wide hips and abundant body Fig. 2 Ceramic figure from Tlatilco, Mexico. Preclassic period. Wide
fat emphasize fertility and nutritional reserves hips suggesting fertility. Also notice antimongoloid slanting of the eyes

Fig. 3 Discobolo by Myron. V Century BC Fig. 4 Aphrodite. A copy of the Greek model by Genga. XVIII Century
The Concept of Beauty in Different Cultures
To the south side of the Mediterranean, the Egyptians,
before the Greeks, produced marvelous sculptures repre-
senting the human body according to the ideal standards of
their culture. In all of them a slim athletic figure is empha-
sized for the Pharaohs and their consorts (Fig. 5). To rein-
force the concept that Egyptian sculptures were carved
representing the ideal of beauty it is convenient to remem-
ber the many images of Queen Hatshepsut who ruled
Egypt from 1479 to 1458 BC. She is always shown with a
slim elegant body but when her mummy was finally identi-
fied in 2007 it was demonstrated that she was a fat lady
with pendulous breasts [6].
Dürer in 1532, following the platonic tradition, published
his work on the mathematical expression of the ideal human
body. His book was translated from the original German ver-
sion into Latin by Joaquim Camerarios the Elder in 1557 and
later into many languages [7]. It is a very extensive treaty on
physical anthropology in which both the male and the female
ideals are analyzed at rest and in motion seen from different
angles (Fig. 6).
Fig. 5 Egyptian sculpture showing a ruler and his consort with athletic
bodies 1500 BC
5
Dürer, a contemporary of Bellini and Andrea Mantegna,
is possibly the most important theoretician in the history of
art sharing this honor with Leonardo. His numerous draw-
ings attest also his quality as an artist. His paintings are mag-
nificent representations of the aesthetic concept of the
Renaissance. “In Adam and Eve” he depicted his ideal of
beauty with lean athletic figures (Fig. 7).
Durer’s meticulous measurements of the different parts of
the human body established a canon widely adopted by his
contemporaries that is still valid today.
This same lean feminine figure was frequently painted
by the most distinguished artists. Examples of that are the
“Venus” of Lucas Cranach and the “Venus in front of a
mirror” by Velázquez from the beginning and the middle
of the seventeenth century, respectively. Simultaneously
other extraordinary artists living in more northern latitudes
such as Rubens painted overweight females like the “Three
Graces.” These works did not pretended to be portraits of a
specific person so we can assume that his choice of models
corresponded to his concept of beauty. Without underesti-
mating the artistic and technical quality of this canvas, the
females painted by Rubens would be candidates for dieting
and extensive liposuction in the twenty-first century
(Figs. 8 and 9).
Sensual feminine representatives of the ideal of beauty
can be observed in the work of Ingres in the nineteenth cen-
tury. The women in his “Great Odalisk” and “Ladies in a
Turkish Bath” are not lean; they are slightly overweight by
the standard of the twentieth century when a trend to
extremely thin female body became fashionable.
We must accept that representations of the human body
made by prominent artists probably correspond to their ide-
Fig. 6 Drawing by Albert Dürer of ideal female body. XVI Century
6 F. Ortiz Monasterio
Fig. 7 Adam and Eve by Dürer.
XVI Century
als of beauty. We also know some painters modified the fea-
tures of their models to conform with the canon.
Nude reclining women are a recurrent subject in paintings
from different epochs. I have selected a few examples in
order to identify the variations of the concept of beauty in the
occidental culture at successive centuries: “The Venus of
Urbino” by Titian in the sixteenth century, “Venus in front of
a mirror” by Diego Velazquez in the seventeenth century, the
lovely voluptuous “Maja Desnuda” by Francisco de Goya in
the eighteenth century, the magnificent “Olympia” by Manet
in the nineteenth century, and the “Seated Nude” by Tamara
de Lempicka in the twentieth century. All of them are excel-
lent examples of feminine beauty representing young women
not very different from each other and very similar also to the
Greek ideals and the Renaissance canon of Dürer and
Leonardo. They all are somewhat different than the athletic
lean models with androgynous overdeveloped musculature
currently emphasized by certain modern publications. There
is a current tendency to reject the extremely thin female figure,
almost bulimic, replaced by a new trend that considers a
heavier even slightly overweight model beautiful. This fuller
feminine figure was also repeatedly painted in the splendid
nudes of Tamara de Lempicka in the first half of the twenti-
eth century (Figs. 10–14).
Pondering over the representations of the human body
over the ages, it is clear that the concept of beauty seems to
be universal; its appreciations is probably not related to the
cognoscitive part of the brain but located in the limbic area.
In spite of its universal character, there are variations
determined by fashion, by race, and by geography. Within
certain limits these variations conform to the canons that
have been accepted over time. In the middle of the twentieth
century, Le Corbusier, the famous French architect, built a
habitational complex in Marseille according to his concept
of adapting the habitat to the physical dimensions of the peo-
ple. This idea was extensively discussed in his book “The
Modulor” [8]. He also congregated a group of anthropolo-
gists, artists, anatomists, and architects to study and to deter-
mine the ideal proportions of the Homo sapiens in the
twentieth century. The results of that work were carved in a
The Concept of Beauty in Different Cultures
Fig. 8 Venus by Lucas Cranach idealizing a lean feminine body. 1506
“stele” similar to the stone monuments of ancient Egypt and
to stelae of the cultures of Middle America designed to com-
memorate important events and to preserve them for poster-
ity. This modern stele was placed at the center of the
habitational complex (Fig. 15).
The measurements analyzed for that monument are
representative of the European population. Their average
height does not correspond to the mean of the population
in many other parts of the world, where people are smaller.
The appreciation of body height has been manifested in
many cultures both for males and females. This concern
had a direct influence in shoe design. We know Catherine
de Medici the wife of the Duke d’Orleans who was a small
person commissioned a cobbler to make her a pair of heels
to increase her height. Those extensions had been used
before resembling the modern platform shoes designed to
protect the wearer when walking in the muddy wet streets.
These extensions of the shoes, originally called “chap-
ines,” became very popular and originated an innovation
of the shoe industry that is maintained at this time. The
7
purpose of elevation of the heel and the plantar area was
to increase height. Later designs, especially the tremen-
dously high heels used by women now, have also affected
the position of the legs and the curvature of the spine forc-
ing the wearer to project the gluteal area in a very attrac-
tive manner. The fashion to increase the apparent height
has extended to the male sex; many men of short stature
wear specially designed shoes or boots to produce that
effect.
It is interesting to mention that Albert Einstein attended a
presentation of The Modulor made by Le Corbusier at Princeton
in 1946. A few days later Einstein wrote him a letter saying: “of
course Mr. Le Corbusier, you are perfectly right; everything
that is right is easy and everything that is wrong is difficult.” In
other words, he was convinced that when a thing is harmoni-
ous, it is found pleasant by everybody.
The human face is the most important element, at least the
most visible of the body and the subject of many of the pro-
fessional endeavors of the plastic surgeon. All the anatomical
structures of the body are supported by the skeleton which
determines its shape and proportions. This is particularly
true for the face [9].
The craniofacial skeleton is responsible for the shape of
the face, for the harmony of its various segments, and it is
also the framework where facial muscles are inserted,
therefore influencing and contributing to expression which is
a very important element of beauty.
The human face is one of the most beautiful structures in
existence. The experienced examiner can easily appreciate
the balance and the harmony between its different elements.
He can also detect the flaws that may alter its balance. It is
convenient, however, to remember a few general rules of
physical anthropology to study the face in a systematic man-
ner. The first step is to locate the points on the soft tissues
corresponding to the skeletal references:
Trichion (TR), nasion (NA), dachrion (DA), subnasal (DA),
alar base (A), stomiun (ST), chirion (CH), and mentón
(M). These references are complemented laterally by
Supraorbital ridge (SO), lateral canthus (LC), temporal crest
(TC), malar (MA), zygoma (Z), and gonion (GO)
(Fig. 16).
Following the mathematical concept of the Golden Rule
to examine a face, we can trace five imaginary horizontal
lines: at the trichion, the nasion, the dachrion, the alar base,
the stomium, and the menton (Fig. 16a).
The face is then divided in five segments that maintain a
relation with each other, which very closely follows the
divine proportion of 1:618 (Fig. 16b).
Analyzing the face as a complete unit the distance TR-DA
is 0.618 and DA-M is 1. Approximately the same ratio is
found when we measure the middle and the lower thirds of
the face.
8 F. Ortiz Monasterio
Fig. 9 The Three Graces by
Rubens. The choice of models
for this canvas illustrates his
concept of feminine beauty
In the ideal face, the diameter between the temporal crests
should be approximately the same as the distance between
the two malar points and to the bigonial diameter.
Facial convexity is an important element of beauty. The
harmonious relationship between the forehead, the nose, the
mouth, and the chin results in a beautiful face. Facial convex-
ity should be evaluated on the profile view tracing an imagi-
nary line following the Frankfurt horizontal plane from the
center of the external auditory channel to the inferior orbital
border. Another vertical line is traced from the supraorbital
notch to the most prominent point of the lower lip. The two
lines should cross each other forming a 90° angle.
The nose should be examined on the full face and the
base views and from the two profiles. On the frontal view
the nasal bridge is seen as two parallel straight or slightly
concave lines extending from the brows to the tip of the
nose. The width of the bridge should be similar to the
distance between the two tip highlights. A slight differ-
ence in height will be visible as shading should be pres-
ent at the tip and the dorsum corresponding to the supratip
break.
The nasal tip resembles the silhouette of a gull wing, the
lateral portions corresponding to the alar notches. A small
portion of the columella should be visible at the center. The
The Concept of Beauty in Different Cultures 9

Fig. 10 Venus d’Urbino by Titian 1558

Fig. 11 Venus looking at a mirror by Diego Velazquez, 1650

10 F. Ortiz Monasterio

Fig. 12 La Maja Desnuda by Francisco de Goya, 1797

Fig. 13 Olympia by Manet, 1863

The Concept of Beauty in Different Cultures 11

2,260

432

432
1,828

863
698

698
1,397

1,130

534
Fig. 14 Seated Woman by Tamara Lempicka, 1929

432
width of the nasal base should correspond to the distance 863
between the medial canthus of the palpebral fissures.
On the profile view the nasal projection is assessed by
drawing an imaginary line from the alar cheek junction to the 698

330
lip. The center of this line should be crossed by the vertical
facial tracing. The columella should be about 4 mm lower
1,130

534
268

than the alar margin exposing the nostrils as narrow ovals.

The accepted ideal nasolabial angle should be 90–105° in
females and 90° in males. 432

204
The forehead should be slightly convex with an average
330
165

height of 50–60 mm [10].

Sophisticated hairstyles cover the scalp of women and also 267
126

of many men. For this reason the shape of the skull in not usu- 204
63 102

ally considered an important factor for beauty. Obvious defor- 165

126
mations resulting from trauma or from birth defects alter the 102
78
proportions of the cranium affecting its aesthetic quality, but,
in general, a round smooth forehead is taken for granted and
little attention is paid to the aesthetics of the skull. 63 48
Early cultures in many parts of the world practiced artifi- 38 30
cial cranial deformations. Pressure was applied with tablets 24 18
to the heads of infants to alter the shape of the head for cos- 15 11
metic reasons. Those early shamans had a good understand- 9
ing of the growth capacity of the cranium. They knew that 6
applying pressure on certain areas of the head the intracra-
Fig. 15 Le Modulor. Study on human proportions. Le Corbusier, 1947
nial expansion produced by the rapid growth of the brain in
an early age would direct the forces to other areas of the
cranial cavity altering the shape of the head.
12
Fig. 16 (a) Anthropometric points on the face corresponding to skeletal references. (b) Ideal facial proportions within the Golden Rule 1:618
Among the Mayas of Mexico and Central America cra-
nial deformation was a common practice. The techniques
they used are well documented and there are numerous skulls
showing the various trends.
The most popular style was the exaggerated slanting of
the forehead which was achieved applying pressure to the
frontal areas. Two more tablets were simultaneously press-
ing the temporal areas to produce a pointed prominent cra-
nial roof. Another option without the temporal pressure
produced brachicephaly. Frontal pressure modified the facial
convexity affecting the supraorbital area and the frontonasal
groove. The distance between the supraorbital ridge to the
anterior surface of the cornea was also altered giving the
effect of a moderate exorbitism. There are many examples of
Maya sculptures representing rulers and other important
people with these features, so we know that this was consid-
ered an aesthetic ideal. There are examples of various cranial
shapes produced by indigenous people in the American con-
tinent. It appears that the preferred fashion varied in each
group. It is interesting to mention that the practice of head
modeling of children is still practiced by some rural groups
in the South American Andes [11, 12].
Also important is the position of the medial and the lateral
canthi. In general, it is considered attractive when the lateral
canthus is 5 mm higher than the medial. There is a tendency to
emphasize this inclination with cosmetics. This so-called mon-
goloid slant of the lid aperture is considered normal in many
cultures and attractive in the world of cosmetics. It should be
mentioned that when the lateral canthus is lower than the medial,
as found is some artistic representations, it is seldom considered
beautiful.
F. Ortiz Monasterio
The prominence of the eye globe from the orbital cavity is
also related to beauty.
The anterior aspect of the cornea should be about 16 mm
in front of the lateral orbital rim. An exaggerated prominence
is not considered attractive.
We know that some of the most outstanding artists intro-
duced subtle changes to the face of their models. In an effort
to please the prominent people who paid high fees for their
portraits they adapted the proportions of the face to the ideal
standards mentioned above. Raphaello himself mentioned
that he had made some alterations to the face of the “Mute
Lady” who was the wife of a prominent merchant of Florence.
If we insert a diagram of the facial skeleton into a photograph
of that painting using the soft tissue references, it is evident
that the skeletal framework fits exactly within the golden
proportion (Fig. 17).
The artistic representation of ideal feminine beauty is tra-
ditionally represented as proportioned harmonious faces
with soft round curves. This is in contrast with the taste for
angularity in our present culture. In the modern face three
prominent areas are emphasized: the supraorbital ridges, the
malar midfacial complex, and the mandibular border. In the
malar midface complex, three zones are important for beauty:
paranasal, the malar prominence, and the projection of the
zygomatic arch.
The prominent areas limit four zones located on a more
posterior plane: temporal hollow above the supraorbital arch
and lateral to the temporal crest, orbital limited by the supra-
orbital ridge and the midmalar complex, the central depres-
sion of the cheek caudal to the malar prominence, and the
neck limited inferiorly by the mandibular edge. In our pres-
The Concept of Beauty in Different Cultures
Fig. 17 The Mute Lady by Raphaello with super imposed skeletal trac-
ing showing golden proportions
ent culture a clear contrast between the prominent and the
depressed areas is considered beautiful. Evidently angular
faces were also considered attractive in other cultures. The
most famous is the head of Nefertiti: one beautiful example
of a feminine angular face.
The beauty of the mouth should be judged in three different
positions. When the lips are closed there should be no visible
muscle strain. In repose a small section of the free edge of the
central incisors should be visible. One to three millimeters of
the superior gingival edge should be exposed during the smile
showing even, white, well-aligned teeth. Incomplete exposure
of the upper incisors or exaggerated gingival show when smil-
ing is the result of disharmony between the skeleton of the
middle and the lower thirds of the face.
The smile is an extremely important element of beauty in
our contemporary culture. This is enhanced by the modern
emphasis on good dental care. Good dentition is a sign of
good health; perfect dental alignment and normal dental
occlusion, very often achieved by sophisticated orthodontic
work, are essential for a beautiful smile (Fig. 18). This was
not always true, artificial dental deformation was practiced in
13
Fig. 18 Margot Hemmingway showing a perfect smile
some early societies. Upper incisors were filed to produce
what was then considered a beautiful smile as in the charm-
ing “smiling faces” of Veracruz, Mexico, from the classic
period (Fig. 19). Dental implants of jade and other semipre-
cious stones have also been found in many cultures associ-
ated with dental deformations. This still is practiced today as
a show of wealth by some people all over the world. In a
more modest scale, gold and other metals are used to cover
incisors not only to replace missing teeth but also as an ele-
ment of beauty and probably as a manifestation of social sta-
tus [13].
Mysterious enigmatic smiles can be observed in the
sculpture of deities in oriental art but are extremely rare in
western art, except in children or very young persons. We
can assume that poor dental hygiene, caries, and loss of teeth
occurring at an early age were prevalent even in persons of
high social status interfering with the aesthetics of the smile.
On the other hand monstrous or ugly persons were often rep-
resented with open edentulous mouths as in the works of
Bruegel and Hieronymus Bosch or in the classical drawings
of Leonardo and others representing older people where the
facial features, mainly the short midface and over rotated
mandibles, indicate edentulous dental arches.
The facial skeleton forms the basic structure for a harmo-
nious face, the musculature is responsible for its animation,
14
Fig. 19 Smiling face showing aesthetic dental mutilation from
Veracruz, Mexico. Classic period
and the skin is the delicate cover wrapping this magnificent
part of the human anatomy. Because of its exposure the skin
has an important participation in the beauty of the body and
especially of the face. Everybody appreciates the marvelous
quality of the skin of children and young people; its tension,
elasticity, and smoothness is maintained for some years,
maybe even decades, before the deteriorating effects of sun
exposure, contact with soap and other chemicals, and age
destroy its original qualities. The passing of time and the
decay of collagen fibers change the original terse surface into
a leathery, spotted draping.
The skin has sebaceous glands that lubricate and protect
its surface. The importance of this oily protection has been
recognized for many centuries. Clothes designed to isolate
the skin from the sun rays and the cold were eventually con-
sidered an element of elegance and beauty. Gloves are used
to protect the hands and lovely elaborated hats shade the face
maintaining the skin quality and beauty. This was empha-
sized in many artistic representations as “The lady of the
mink” by Leonardo, who also has perfect harmonious pro-
portions. The beauty of the skin of ladies like “Saint
F. Ortiz Monasterio
Fig. 20 The Lady of the Mink by Leonardo. Perfect facial proportions
and immaculate skin of the face and hands
Margaret” painted by Zurbarán can be admired at the Prado
Museum in Madrid and the texture of the hands and face of
the Countess of Newcastle painted by William Larkin exhib-
ited at the Tate Gallery in London (Figs. 20 and 21).
Skin color is also an element of beauty. The presence of
melamine acts as a filter to protect it against the ultraviolet
rays, but continued sun exposure results in pigmentation that
has been considered attractive by several generations of sun
worshipers during the twentieth century, associating skin
pigmentation with health and, eventually, paying the price
with premature aging and skin cancer.
The immaculate nonpigmented white skin was consid-
ered essential for beauty for many centuries. This concept,
related to a cultural xenophobic attitude, has changed. Darker
skin common to many ethnic groups and its many variations
are now considered attractive as evidenced by the photos of
beautiful models in the fashion literature (Fig. 22).
Other glands complement the complex function of the
skin. Sudoriparous secretion maintains humidity and surface
temperature; eccrine glands produce pheromones related to
sexual stimulations. Its odor is characteristic and considered
unpleasant in modern society specially when combined with
The Concept of Beauty in Different Cultures
Fig. 21 Saint Margaret by Zurbarán emphasizing skin perfection, 1634
the acrid smell of retained sebaceous material and its bacte-
rial complement in persons not addicted to water and soap.
Modern humans are not only sun worshipers, we are also
soap worshipers who consider skin odors unpleasant. Modern
hygienic habits deprive the skin of its protection.
This custom of a frequent bath has been accepted and
rejected in different epochs. The Romans considered their
baths as an enjoyable experience and an opportunity for
social intercourse. In other cultures this practice was not
accepted and even considered dangerous.
With regards to beauty, hygiene and body odors, it is
amusing to remember the opinion of Bartolome Angelico in
his “De propiertatibus serum” published in 1601 who wrote:
Beauty consist on the elegant disposition of the body and its
perfume. Also the anecdote of Gabrielle d’Estreés, the king’s
mistress, whom he found irresistible. In fact Henry IV wrote
her a passionate letter saying: “please madam don’t take a
bath, I will arrive in three weeks.” We may not coincide with
the king’s taste for body effluvious but certainly will agree
15
Fig. 22 The human skin used as a canvas
with him about her beauty as seen in her portrait by the
school of Fontainebleau in 1595 (Fig. 23). Considering that
the appreciation of beauty is also a sensual experience,
visual, tactile, and olfactory, I believe that the smell of a per-
son, enhanced by the use of perfumes prevalent in our soci-
ety, should also be considered an element of beauty.
Skin ornamentation has always been used to enhance
beauty; to celebrate festivities; to mark rites of passage; to
identify a person with a certain group, clan, or sex; to frighten
enemies; to give protection against evil spirits; and many
other reasons.
Tattooing, painting, piercing, and scarifying the skin for
purposes of beauty have been practiced since time immemo-
rial. Tattoos were found on the skin of the 5,600-year-old
mummy found on the Italian Alps in 1991 as well as in many
African cultures and on the skin of many people in the
twenty-first century. Piercing of the ears has been a common
aesthetic practice for many generations, and jewels inserted
in piercing of the lips, the tongue, the brows, and the navel
considered attractive in many cultures are again a relatively
common practice among young people.
16
Fig. 23 Beatriz d’Estrées portrait of the School of Fontainebleau, 1595
The artistic application of pigment to the skin may follow
geometrical patterns representing abstract concepts or as imita-
tions of the skin of animals, usually totemic gods, or to alter
certain anatomical features like skin and hair color, to suggest
youth, or to conform to aesthetic preferences like the white
paint used by geishas in Japan. The human skin has also been
used as a canvas by artists following the tradition of the ancient
shamans who decorated the skin of the members of the tribe. A
relatively common practice is to paint garments on a naked
person, usually women, and to represent abstract designs inter-
acting the pigments with the contours of the body such as the
interesting project of the “Painted Bodies” produced by
Edwards in Chile with the participation of many artists.
The body ornaments are a part of the concept of beauty in
every culture in all parts of the world from the most primitive
to the most sophisticated modern people. The skin is the
window case of beauty. But it is much more than that; the
F. Ortiz Monasterio
skin is a site of beauty, the playground for the perpetration of
our species, the soft cover passionately attractive to sur-
geons, photographers, lovers, and poets.
Acknowledgement This chapter was edited by Dr. Fernando Molina
following the death of Dr. Ortiz-Monasterio. Dr. Molina commissioned
the artist, Eduardo Talledos, to make renderings of the original works of
art that are referred to in the text.
References
1. Vitruvio P (1995) Los diez libros de la arquitectura. Alianza
Editorial, Madrid
2. Itinerarium mentis in Deum (1989) Bonaventura de Bagnoregio
XII Century. In: Tatarkiewicz W (ed) Historia de la Estética.
Ediciones Akal, Madrid
3. d’Aquino T (1995) Summa Theologica. In: Tatarkiewicz W (ed)
Historia de la Estética. Ediciones Akal, Madrid
4. Vesalius A (1543) De Humani coporis Fabrica. School of Medicine,
Padua, Italy
5. Genga B. Anatomy improved for artists 1672. Reingraved in
London 1773 by Senex, John
6. Brown C (2009) The woman who would be king. Nat Geosci 216:4
7. Duero A (1987) Los cuatro libros de la simetría de las partes del
cuerpo humano. México Biblioteca Nacional, Instituto de
Investigaciones Bibliográfias, Universidad Nacional Autonóma de
México, Coyoacan, México
8. Le Corbusier, Pierre Margada (eds) (1987) Galerie des Princes, Le
Corbusier Foundation, Brussels, Belgium
9. Livio M (2002) The golden ratio. Broadway Books, New York
10. Ortiz Monasterio F, Molina F (2005) Cirugía Estética del Esqueleto
Facial. Editorial Panamericana, México
11. Vera T (2008) El modelado del cráneo en Mesoamérica.
Arqueología Mex 16:94
12. Tierser Blos V (1977) El aspecto físico de las mayas. Arqueología
Mex 5:28
13. Verut D (1973) Precolombian dermatology and cosmetology in
Mexico. Chantieleer Press, New York
 Is There a Frontier Between Aesthetic
and Reconstructive Surgery?
Daniel Marchac †
Plastic surgery is facing a major problem: the risk of a split-
ting, a divorce between the aesthetic and reconstructive parts
of our speciality – the public hospitals dealing with the
reconstructive cases, the private hospitals and private offices
dealing with the lucrative aesthetic surgery.
For the public and the medical world, plastic surgeons are
viewed more and more like aesthetic surgeons, and this
image is negative: no more really doctors but moneymaking
beauticians!
It is fundamental for our survival that we realize that and
react. We must explain and demonstrate that our speciality
has two aspects which are complementary and, in fact, so
close, the reconstructive and aesthetic parts.
We must explain that the techniques utilized for the aes-
thetic operations and for the reconstructive operations are the
same and have to be learnt during the plastic surgery train-
ing: handling of the skin, flaps, facial bones surgery, etc.
We have to remind that complications can happen after
any aesthetic operation: a skin necrosis, an infected haema-
toma and a scar retraction. They require a good knowledge of
plastic surgery basic principles to be treated, and that it is not
a basic formation of the “five main aesthetic operations” that
can provide security to the patients.
Training in aesthetic surgery is a key issue for the future
of our speciality. Many other specialities are attracted by aes-
thetic surgery and want a part of the cake. The facial special-
ists want to do the face lifts, rhinoplasties and eyelids, the
gynaecologists want to do the breast correction and the gen-
eral surgeons the breasts and abdominoplasties.
Of course we are trying to spread the message that aes-
thetic surgery should be done by certified plastic surgeons.
† Daniel Marchac passed away in October 2012. Correspondance
should be addressed to his son Alexandre Marchac.
D. Marchac, MD
Craniofacial Unit, Hopital Necker Enfants Malades,
Paris, France
e-mail: alexandremarchac@gmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_2
Many national societies and qualification diplomas have the
word “aesthetic” mentioned besides plastic surgery, but we
must realize that the public does see much differences
between us and the “facial plastic surgery” specialists, or
even “certified cosmetic surgeons”, with beautiful framed
diplomas!
Therefore, besides the message that the real good training
to do aesthetic surgery is plastic surgery, we must effectively
train our residents to be the best in aesthetic surgery.
At the present time, the training is focused on basic prin-
ciples and reconstructive surgery, and little is done in most
teaching programmes in the aesthetic field. Many residents
also consider that aesthetic surgery is simple, and that they
will easily perform these few operations when they will
need to.
In the competitive world they are entering they must real-
ize that they must be the best, and that aesthetic surgery is
full of difficulties when one is willing to achieve an excellent
result.
Of course, many teaching hospitals are very busy with
reconstructive cases and do not have time, and operative
space, for aesthetic surgery. The utilization of plastic sur-
geons working privately could be a solution, since many
would be happy to give some of their time, especially at the
end of their carrier, to teach residents. They could give some
lectures in the public hospitals and accept residents to
observe their surgery in private practice. A different solution
has to be found for each country and local situation, but the
basic point is that our plastic surgery residents must have an
excellent training in aesthetic surgery, to be the best surgeons
when they confront with the competition, and it is not the
case now for most programmes.
Coming back to the title of this chapter, I want to demon-
strate that the boundaries between aesthetic and reconstruc-
tive surgery are difficult to determine. On a practical point
one can say that what is covered by health insurance is
reconstructive and what is not covered is aesthetic. Not so
simple: why bat ears are covered by social security in France,
while a big hump on the nose is not? The administration
17
18
explains that bat ears create a psychological trauma to the
child. What about a big nose or small breasts which are not
covered? The tendency of the various health insurances is of
course to classify all the morphological corrections as “aes-
thetic surgery” and to refuse to cover them. Coverage for
congenital anomalies or traumatic sequelae without func-
tional problems is more and more difficult to be accepted in
several countries.
So we must fight the way our American colleagues of the
ASPS have done, going to the Congress to obtain that the
insurance companies will be obliged to provide coverage for
the congenital malformations with morphological anomalies
but without functional problems.
We must understand that most of the political personnel,
like the general public, have a negative image of plastic sur-
gery, and we must explain them the immense benefits we
bring with our reconstructive skills applied to morphological
problems and that aesthetic surgery, well performed, with
good indications, is beneficial to many patients.
In order to obtain insurance authorization for the cases
that we think should be covered, like macromastia or exci-
sion of major excess skin following weight loss, we must not
attempt coverage for cases which are borderline. Too many
rhinoplasties are listed as deviated septums and blepharo-
plasties as blepharochalazis. There is also a tendency to uti-
lize a minor procedure (ie: small tumour removal) to obtain
hospital coverage for, as an expample, a face lift. This can be
very detrimental by casting suspicion on all our procedures
and should be strictly avoided.
I would like to show a few clinical cases to illustrate the
difficulties of drawing boundaries between reconstructive
and aesthetic surgery.
Case 1: Cervical Tumour Operated via a Face Lift
Approach This 54-year-old patient was sent to me for
removal of a big lipoma on the right side of the neck, below
the parotid region. The MRI showed that it was located under
the SMAS level. The patient was concerned about a visible
scar and was aware of the sagging of her lower face. It was
decided to perform a facelift that gave an easy access to the
lipoma after SMAS elevation and allowed to obtain an aes-
thetic improvement of her appearance. The insurance com-
pany covers the hospitalization and part of the fees, the
patient paying for the additional time linked to the face lift
operation (Fig. 1).
Case 2: Baso Cell Carcinoma Permitting a Refinement of
the Nose This patient, aged 70, was referred to me for
removal of a small baso cell carcinoma of the nose, located
above the tip, on the midline. She was of course very con-
cerned about scarring or distortion and complained of a bul-
bous tip. The midline removal of the skin, the remodelling of
the underlying cartilages to narrow the tip and increase
D. Marchac
projection, associated with lateral skin undermining, allowed
for a suture with limited tension. The insurance company
pays for the tumour removal and repair. My fees were slightly
increased because of the additional work compared to a sim-
ple closure of the defect (Fig. 2).
In these two cases, the benefit for the patient is obvious:
coming for a tumour removal, they are not only cured, but
also embellished. The double expertise in both reconstruc-
tive and aesthetic fields is mandatory to obtain the best out-
come in such cases.
In the field of craniofacial surgery, there are also cases
which are borderline.
Case 3: Minor Midface Retrusion, Facial Advancement
This 15-year-old young girl had a mild form of Crouzon dis-
ease, with a cranial release in infancy and a perfectly normal
development. She had an acceptable occlusion, but was con-
cerned by the flatness of the mid face with recessed malar
bones and mild exorbitism. A classical Le Fort III facial
advancement improved greatly her facial balance. Since the
patient had Crouzon disease, the insurance covered without
discussion the osteotomy operation. This was an aesthetic
operation but doesn’t the patient with a congentital malfor-
mation have the right to have insurance cover even border-
line procedures? (Fig. 3).
Case 4: Facial Asymmetry due to Moderate Orbital
Dystopia, Orbital Shift This 31-year-old good-looking girl
complained of a facial asymmetry. In fact, everything else
being strictly normal, she had a difference of level between
the two orbits of about 6 mm. The aesthetically pleasant
solution was to elevate the right orbit. To be sure not to dete-
riorate the satisfactory shape of the eyelids and canthal
attachments, the only solution was a four walls orbital en
bloc upper displacement. This involved an intracranial
approach to remove part of the frontal bone and get access to
the orbital roof. This significant operation seemed at first out
of proportion with the moderate asymmetry. The patient
insisted to have it done, signed all the information and con-
sent forms and accepted also to cover the expenses since I
considered that social security had not to pay for this aes-
thetic craniofacial operation. The operation turned out well,
and she was very pleased with the result. There were no early
or late complications (Fig. 4).
Case 5: Cranial Remodelling in Adults This 26-year-old
man complained of an abnormal shape of the head, with a high
and bulging forehead. It was an obvious sequalae of an unop-
erated scaphocephaly type of craniosynostosis. The diagnosis
was not made when he was an infant, he had no functional
impairment and was an engineer; his problem was the abnor-
mal shape. The only way to correct was a fronto-cranial
remodelling, elevating the affected parts and reconstructing a
Is There a Frontier Between Aesthetic and Reconstructive Surgery? 19

c d e

f g

h i

Fig. 1 (a, b) A 54-year-old woman presenting with a lipoma of the neck. (c) The lipoma is well visible, under the SMAS. (d, e) The lipoma is
easily dissected with this wide approach. (f, g) Before and 3 months after surgery. (h, i) Before and 3 months after surgery
20 D. Marchac

a b

c d e

Fig. 2 (a) A 70-year-old patient, baso cell above the tip of the nose. (b) excision will be made for this midline lesion. (d) The exposed carti-
Three months after midline resection with cartilage remodelling. (c) lages have been narrowed and brought together to increase projection.
After frozen section control, the extent of the resection. A vertical (e) Careful suturing in two layers
Is There a Frontier Between Aesthetic and Reconstructive Surgery? 21

Fig. 3 (a–c) A 15-year-old Crouzon patient

with malar flattening. (b–d) Six months after
a b
Le Fort III facial advancement. (e, f) Before
and after the facial advancement. The occlu-
sion was acceptable before surgery. The indi-
cation was purely aesthetic

c d

e f
22 D. Marchac

a b

c d
e f

Fig. 4 (a) A 31-year-old woman presenting an asymmetry of the face. computer, a project of the 6 mm elevation of the right orbit. (e, f) Before
(b) The right orbit is lower, all other skeletal elements being symmetri- and 3 months after correction of dystopia
cal. (c) The right orbit will be mobilized as a ‘“box”. (d) On the
Is There a Frontier Between Aesthetic and Reconstructive Surgery?
skull of a better shape after displacement and remodelling of
the bony pieces. The supraorbital part was of a normal shape,
so there was no opening of the frontal sinus, diminishing the
infection risk. The bone is hard to cut and to mould in an adult,
but the intracranial risk is very little in trained hands. A preop-
erative project, to both plan the repair and obtain the agree-
ment of the patient, is very helpful (Fig. 5).
The operation went without problem; the patient stayed 3
days in the hospital and had a very fast recovery.
Since it is the sequalea of a craniosynostosis, the social
security covered the cost of the surgery, even if it could be
argued that this is only an aesthetic demand, and in many
countries the demand of coverage would be refused for such
cases.
Case 6: Aesthetic Operations at Completion of Craniofacial
Corrections This typical Crouzon patient had all the usual
treatments: early frontal advancement, Le Fort III at 6 and
again at 14 years of age. When the skeletal base is corrected
and stabilized, aesthetic surgery techniques are utilized to
get the best possible appearance: rhinoplasty, genioplasty
and fat injection in irregular areas (Fig. 6).
To get this “best” possible result, it is fundamental that
the craniofacial surgeon has the practice of aesthetic surgery,
firstly to evaluate the face and to see what can be done to
improve it, and secondly to be able to do it! The knowledge
of what has been done before, and of the possible modifica-
tions, bone plates and so on, is also helpful.
For these purely aesthetic procedures after craniofacial
procedures, in our countries, insurance companies will pay
without much discussion since it is linked to the congenital
anomaly. It can be discussed, and if the family could pay the
expenses, I would rather think that they must do it.
With theses few cases, I have tried to demonstrate the dif-
ficulties of making a “frontier” between the two parts of our
speciality, and that expertise in both aesthetic and recon-
structive surgery is fundamental to our speciality, to get the
best possible treatment for our patients.
This is again my plea for “walking on two feet”, but it is
interesting to realize that the attitude of plastic surgeons
towards the two aspects of our speciality has varied consider-
ably. Since the beginning of the twentieth century, aesthetic
operations were done, but not put forward by the pioneers,
Sir Harold Gillies, Mac Indoe, etc. Madame Noel was a
french surgeon who practiced aesthetic surgery under local
anesthesia in her apartment. Her book “La Chirurgie
Esthetique, son role social” (Aesthetic Surgery: It’s social
role) was published in 1926. She writes that aesthetic sur-
gery helped patients to improve or keep their jobs, prevented
divorces by reversing aging, etc.
The Second World War of course put forward the recon-
structive side of our speciality. In France plastic surgery had
23
nearly disappeared in the 1930s after a dramatic amputation
had to be made to a young woman after fat removal by a
famous surgeon. It was followed by a trial and a judgement
disapproving radically all aesthetic operations!
There was no more plastic surgery training in the public
hospitals in France after the early death of Hippolyte
Morestin from the Spanish flue in 1919, only some aes-
thetic surgeries were done in private hospitals, with discre-
tion. After the Second World War, the young French plastic
surgeons interested in the field went to learn the basic prin-
ciples of plastic surgery in England, like Tessier and
Morel-Fatio, or in the United States like Claude
Dufourmentel.
Their aim, like in most countries, was to have the spe-
ciality recognized and to create departments of plastic sur-
gery. They knew that the aesthetic side was ill considered in
the medical world and they were carefully hiding it. In
Morel-Fatio unit (it was in fact a general surgery unit with
an orientation on plastic surgery) it was forbidden to pro-
nounce the word “aesthetic”, only plastic was allowed! In
1957, Dufourmentel wrote a paper about plastic surgery
and made a distinction between the reconstructive aspect
“the most interesting” and the corrective aspect, which
included the aesthetic operations, without mentioning the
word aesthetic! [1]
So, like them, most plastic surgeons were doing both
reconstructive and aesthetic surgery, but were nearly hiding
the aesthetic side.
In 1966, Mario Gonzalez Ulloa published a “Manifesto”
on the field of aesthetic surgery that he believed should be
the concern of plastic surgery. He claimed that the aesthetic
operations should be studied, taught and analyzed like any
other surgical field. He writes: I protest against the academic
lack of appreciation of aesthetic values in Plastic Surgery, I
protest against the absence in our teaching programs of the
study and appreciation of beauty… [2].
Another plastic surgeon, Ivo Pitanguy, who did much to
promote the image of plastic surgeons being the beauty spe-
cialists had a different approach when he wrote in 1983
“Since a long time, I wanted that the acclaimed reconstruc-
tive surgery, and the ignored and often despised aesthetic
surgery, unite into plastic surgery. This has been the main
goal of my life!” [3].
Very carefully he always mentioned his reconstructive
cases besides the aesthetic propaganda. It is interesting to
realize that for the lay public and other doctors, he has this
image of a plastic surgeon treating the disfigured as well as a
famous aesthetic surgeon. We know that his activity was
mostly aesthetic, but he was successful in projecting this
positive image.
We should, as he did, always mention reconstructive
aspects when we talk about aesthetic surgery, and the oppo-
24 D. Marchac

Fig. 5 (a, b) Bulging and exagger-

ated height of the forehead in a a b
26-year-old man with sequalae of
unoperated scaphocephaly type of
craniosynostosis. (c, d) Six months
after fronto-cranial remodelling for
aesthetic reasons. (e, f) 3D reforma-
tion before and after remodelling.
The upward projection has been
diminished and the skull widened

c d

e f
Is There a Frontier Between Aesthetic and Reconstructive Surgery? 25

Fig. 6 (a, b) A 2-year-old Crouzon girl,

before frontal advancement. (c, d) At 6 years a b
of age, after Le Fort III facial advancement.
(e, f) At 14 years of age, before Le Fort I and
genioplasty. (g, h) At 20 years, after rhino-
plasty and fat injections

c d

e f
26
Fig. 6 (continued)
g h
site, mention aesthetic problems when reconstructing. I
recently realized during a meeting with medical journalists
that many of them did not understand that we, plastic sur-
geons, are doing reconstructive and aesthetic operations.
Being approached often by aggressive aesthetic surgeons,
they did not realized that the vast majority of us is practicing
every day, without publicity or media coverage, these two
aspects of our wonderful speciality!
D. Marchac
References
1. Dufourmentel Cl (1957) Etat actuel et évolution contemporaine de la
chirurgie plastique. Problémes. Revue de l’association générale des
étudiants en médecine de Paris 47:14–41
2. Hage J, Gonzalez-Ulloa J (2002) Manifesto in aesthetic surgery.
Plast Reconstr Surg 110:1171
3. Pitanguy I (1983) Les Chemins del la beaute. Un maitre de la chirur-
gie plastique temoigne. J.C. Lattes, Paris
 Indications, Psychological Issues
and Selection of Patients in Aesthetic
Surgery
Nicolò Scuderi, Bryant A. Toth, Stephen P. Daane,
and Diego Ribuffo
1 Introduction
Personal identity is the definition of an individual in relation to
himself and others. The body represents one of the fundamental
aspects of personal identity, as for each individual it is unique; it
is the manner of communicating with the world and can be con-
sidered either in an objective or in a subjective way. “I am my
body” or “I see and feel my body as tall, short, thin etc.”
It is important to distinguish body from body image, which
can be defined as the tridimensional image that each of us has
of himself in his mind, or the ideal representation of our body
in our mind. Obviously, this body image is conditioned by
socio-cultural factors, by interpersonal experiences, by physi-
cal features and personality traits and, last but not least, by the
age of the individual. Actually, age and maturity enhance
body image definition. During the life span, body image is in
a continuous process of change and requires an everlasting
resetting of one’s identity: thus, any time that body image is
modified, one’s identity is somehow altered as well. Plastic
surgery modifies the body and changes body image, requiring
an adaptation of one’s identity; this process proves easier in
younger individuals but more complex either in mature per-
sons or in subjects of advanced age. Thus, plastic surgery pro-
cedures have considerable implications on the psychology of
operated patients. Not considering plastic reconstructive sur-
gical procedures, in which an anatomic and/or functional
N. Scuderi, MD
Dipartimento di Chirurgia, Università di Roma “Sapienza”, Rome, Italy
B.A. Toth, MD, FACS
Private Practice, Toth Plastic Surgery, San Francisco, CA, USA
Clinical Professor of Surgery, University of California, San Francisco,
CA, USA
e-mail: tothbryant@gmail.com
S.P. Daane, MD
Private Practice, San Francisco and San Ramon, CA, USA
D. Ribuffo, MD
Dipartimento di Scienze Chirurgiche e Odontostomatologiche,
Università di Cagliari, Cagliari, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_3
fault is present, requiring corrective measures, in aesthetic
surgery the indication to the procedure is exclusively a sub-
jective one and stems from the patient’s will to modify his
own body image and, at least in part, his own identity. The
absence of an objective indication to surgery makes the aes-
thetic side of surgery and medicine different from both tradi-
tional surgery and medicine, as in these situations a pathologic
condition pointing towards a therapeutic measure is invari-
ably present. Thus, it is necessary to reach an in-depth under-
standing of this problem – while at the same time looking for
the correct indication to surgery – as well as selecting patients
according to criteria which are both sound and safe. It is also
important to avoid any involvement with subjects prone to
therapeutic failures, which in these cases may not be due to a
surgical pitfall but may simply be the result of a misunder-
standing between the surgeon and his patient. According to
these statements, a background in basic psychological prin-
ciples is essential for the plastic surgeon wishing to provide
optimal care for aesthetic patients. An understanding of these
principles will help to identify cases in which the intervention
of a psychologist is essential, and can assist in relieving
patients’ of feelings such as anger or depression that may
occur in the postoperative period. Understanding the psychol-
ogy of aesthetic surgical patients can make the management
of frustrated subjects much easier.
In this chapter the psychological evaluation and the
description of personalities have been referred by the authors
to an analytic dynamic model.
2 Traditional Beliefs Regarding
Aesthetic Surgery and Psychological
Stress
We have already stated that the knowledge of basic psycho-
logical principles is essential for the plastic surgeon wishing
to provide optimal care for aesthetic patients. Understanding
the psychology of patients can effectively simplify the clini-
cal course of difficult cases.
27
28
The level of dissatisfaction towards a part of one’s body
or towards the aspect of a part of one’s body seems to be
significantly related to the patient’s personality. Following
the stress of a surgical procedure, a patient can lose his psy-
chological equilibrium and, according to his personality,
can present symptoms of variable evidence and
seriousness.
The first papers in literature dealing with the psychologi-
cal aspects of plastic surgery revealed the importance of
investigating familiar issues in problematic patients, to fore-
see and prevent any eventual psychological mishaps to sur-
geons. Different procedures in aesthetic surgery such as
rhinoplasty, additive and reductive mammoplasty, ortho-
plasty, etc., can induce psychological modifications, as they
are responsible for major alterations of body image.
According to scientific literature, the main organs leading
to important changes in body image after a surgical proce-
dure are the nose, breast and face.
Nose: more has been written about the psychological
aspects of rhinoplasty than about any other aesthetic opera-
tion. Early psychological studies of rhinoplasty patients sug-
gested that they were more unstable than the general
population, and that among them there was an overwhelming
number of neurotic subjects. Recent investigations per-
formed using psychological tests such as the MMPI
(Minnesota Multiphasic Personality Inventory) showed that
operated patients were within normal limits; no differences
were found between rhinoplasty patients and the normal
population. If a good surgical result induces discomfort, then
it is probable that the underlying problem was not merely an
aesthetic one.
Breast: the psychological impact of a breast operation
cannot be dissociated from the patient’s acceptance of or
conflicts about her own sexuality and femininity. Most breast
augmentation patients have felt inadequate since adoles-
cence; they are sexually inhibited and experience feelings of
inferiority in relation to friends and other adolescents.
Face: facelifts are performed to recreate a previously
existing condition. It has been hypothesized that body image
does not age as rapidly as the physical body itself and, thus,
whether or not this is so, the facelift seems to have no dra-
matic requirement of body image readjustment. Bringing the
face image back into the past, the procedure re-establishes a
condition of normality in the subject and, thus, variations of
personality are less dramatic compared to what happens
while operating on the breast or nose. In the series by Goin
& Goin [1], the motivations for operation were related to
feelings about aging in different ways. All of these patients
expressed satisfaction with the results of the operation,
although in separate surveys on facelift patients one in eight
expressed general dissatisfaction with the operation. Younger
facelift patients showed a greater improvement in their inter-
personal relationships than older subjects.
N. Scuderi et al.
3 Personality Types in Aesthetic
Surgery Procedures
Many forces act in combination to produce a personality pat-
tern; among the most important of these is the stress associ-
ated with childhood separation and individuation. Classic
psychoanalytic theory shows that a personality type is distin-
guished by a particular set of mechanisms for coping with
the fear of separation and the psychic pain associated with
loss. Defence mechanisms operate automatically outside of
an individual’s awareness without harmful effects and make
it possible for unpleasant experiences to be forgotten,
anxiety-producing anger to be denied and forbidden desires
avoided.
Psychological and clinical theories, substantiated by evi-
dence from neuroscience and by recent discoveries in brain
research, underline the possibility of changing, adapting and
exerting a continuous, positive search for personal harmony.
There are different personality types that we are not going
to fully examine here; we will briefly underline the following
four variants that can more easily be related to postoperative
problems: (1) the passive-dependent personality, (2) the
obsessive-compulsive, (3) the narcissistic and (4) the para-
noid. It is also necessary to pay attention to phobic and
depressed patients and to subjects showing disturbed nutri-
tional behaviour [2].
3.1 Passive-Dependent Personality
Passive-dependent persons are compliant; they push their
own wishes and aggressive tendencies into the background
because it is more comfortable for them to depend on other
people. They have dealt with separation- individuation anxi-
eties by finding substitute parents whom they can lean on. If
the stress of an operation stirs up childlike fears, the passive-
dependent may regress into a clinging, dependent type
patient. When a coping mechanism works well, it helps an
individual to get what he or she wants; the unfortunate thing
about an imbalanced or exaggerated defence mechanism is
that it can drive people away. Those caring for passive-
dependent patients need to see beyond the exaggerated com-
plaints of the terrified “child” who is expressing them.
3.2 Obsessive-Compulsive Personality
People with the obsessive-compulsive personality type cope
with life’s stress by keeping things in order. They deal with
emotions by pushing them aside, denying that uncomfortable
feelings exist or giving intellectual explanations for them.
When working well, this personality structure can help its
owners both lead productive lives and achieve high goals.
Indications, Psychological Issues and Selection of Patients in Aesthetic Surgery
When the obsessive-compulsive order-imposing mecha-
nisms are overloaded with emotions which are too strong,
imbalance occurs. It may be impossible to reason with these
patients; rather, it may be necessary to prescribe a complex
postoperative regimen for the OCD patient, so they can
“remain in control”.
3.3 Narcissistic Personality
Narcissistic individuals are people with very low self-esteem,
who place great importance on their physical appearance
because fundamentally they believe that they possess noth-
ing else which is of value. Narcissistic women frequently use
seductive behaviour to get what they want; narcissistic men
may project hyper-masculinity. For these patients, any surgi-
cal operation is a potential source of great anxiety, since it
affects their all-important body. The surgeon must demon-
strate patience and forbearance. Fortunately, after weeks of
worry, the usual result is exaggerated enthusiasm about the
outcome.
3.4 Paranoid Personality
Paranoid people manage unacceptable thoughts and feelings
by projecting them outward and attributing them to others. It
is always the other person who is thoughtless, not to be
trusted or potentially hostile. This mechanism works well as
long as such people feel in control, but it backfires when they
have to depend on someone who is seen as potentially dan-
gerous. Under the normal circumstances of everyday life,
such individuals can function effectively, but the paranoid
trait may be intensified by the stress of surgery. If the para-
noid protective mechanism backfires, it can provoke rage.
The surgeon must answer all questions in a firm manner so
that the patient feels the surgeon is both competent and
authoritative, even if the patient’s anger gets out of control.
4 Preoperative Evaluation
Tests exist for a psychological evaluation as well as for a
preoperative psychological examination for aesthetic surgi-
cal patients, even if often surgeons rely on instinct and on
their attitude to evaluate patients. Some patients such as par-
anoid subjects who hope to catch the surgeon off guard in
order to gain control over the “dangerous” adversary can be
easily identified. Obsessive-compulsive subjects are deter-
mined in that they ask questions intensively, for the mere
reason of relieving the anxiety that results from a sense of
being out of control; in other situations, personal and famil-
iar features can identify a subject who will probably not be
29
satisfied with the results of aesthetic surgery. Misjudgements
can be kept to a minimum if the surgeon shows both the abil-
ity to listen and common sense. A few key questions can be
useful, as these will illustrate the psychological portrait of
the patient by means of the relative answers. These questions
are as follows: (1) The reason why the patient requires sur-
gery; a realistic motive is a good starting point. Otherwise, if
it proves fancy or indefinite, such as to please someone else,
or change one’s life or work, this is an inadequate answer. (2)
Another topic is anxiety related to the surgical procedure; the
surgeon has to check whether the patient is extremely anx-
ious or depressed in relation to his aesthetic imperfection; in
this case, it is best to verify the situation before going ahead
with surgical planning. (3) Another critical point is the per-
spective the patient has developed of his own defect. Ill-
defined answers such as “I cannot see myself this way
anymore” or “I reject my image” or “I want a nice, provoca-
tive breast” and so on. All of these are less than acceptable
answers. It is important to obtain answers providing evidence
of comprehension and realistic expectations of the surgical
procedure from the patient. (4) It is important to evaluate the
social motivation for surgery, whether the procedure is linked
to an individual desire or to interpersonal relations, as condi-
tioning by other subjects proves less positive in determining
the surgical choice. (5) The patient’s status also has to be
considered, together with professional aspects and personal
ambitions, as subjects requiring surgery in relation to their
work or expecting advantages in the work environment must
be carefully evaluated before surgery.
The aesthetic plastic surgeon should make every effort to
find out what patients expect from surgery. Accurate patient
selection is crucial for avoiding postoperative problems in
aesthetic surgery. Anatomical suitability and adequate surgi-
cal technique represent the traditional criteria of the surgical
indication, to which patient’s motivation has to be added.
Lack of motivation precludes progression towards surgery.
Furthermore, a strongly motivated patient will experience
less pain, a better postoperative course and significantly
higher index of satisfaction. Cultural beliefs, such as those
related to Puritanism, can evoke stigma associated with cos-
metic surgery and the same can occur due to the legacy of an
excessively strict education, leading to a sense of shame;
these conditions can affect the patient’s perioperative experi-
ence and satisfaction.
5 How to Avoid Medical-Legal
Problems
Differences exist regarding this topic between the United
States and Europe. In the United States, for a guilty verdict,
four components must be present simultaneously: (1) the duty
to treat must exist for the surgeon, (2) an injury must be present,
30
(3) an adverse deviation from the standard of care must be
proved and (4) a connection between the deviation and the
injury must be proved. To the contrary, in Europe and in Italy
in particular, medical malpractice is related to inexperience,
imprudence and lack of observance of laws and rules.
Generally speaking, plastic surgery procedures need to be
updated or altered in one way or another. This does not mean
that surgeons commit malpractice or behave in an imprudent
or an inexperienced way. In the field of plastic surgery not all
the procedures are strictly codified, but individual adjust-
ments are expected. Yet, a deviation from the standard of
medical care is often at the heart of a malpractice action.
There must be a clear connection between the deviation and
the injury and the surgeon must be proven guilty. Sometimes
an injury exists, but there is no causal connection with the
surgical procedure. It is also possible that evidence of a det-
rimental deviation or lack of observance of rules is utilized
by the attorneys to push the court towards a guilty verdict.
This is the case of a patient requiring bariatric surgery in
whom the surgeon elects not to have blood cross-matched;
medical malpractice is eventually foreseen, even if the injury
has no relation to hypovolemia: evidence of a detrimental
variation can be used to prove that the physician was inade-
quate in preparing the patient for the procedure.
In aesthetic surgery a discrepancy between the surgeon
and the patient may be more often observed in relation to the
duty to treat and to the indications to operate. In traditional
surgery the indication stems from the pathologic condition
requiring treatment. In aesthetic surgery the duty to treat is
bound only to a request from the patient who is willing to
alter his body image. This is the reason why informed con-
sent proves to be crucial; surgeons try in every way to
improve it and to include it in the text statements from the
patient.
Informed consent is specifically dealt with in the chapter
dedicated to medical-legal aspects; it is necessary to under-
line here that in relation to the informed consent, the impor-
tant point is not represented by its length or the kind of
information given, but rather by the certainty that the subject
has fully understood the message. It often happens that a
patient criticizes an otherwise perfectly good result because
he did not realize the pain, the time and the expenses involved
in the surgical procedure in advance or, similarly, had no idea
regarding the appearance of the scars or of the limitations
connected with surgery. Occasionally, the patient has no
knowledge of the surgical plans simply because the surgeon
himself has no clear idea of what he is going to perform.
Surgical improvisation in the operating room can result in
being extremely harmful. The surgeon has to discuss the
terms of the procedure meticulously before starting.
Among the worst cases are those in which, even after a
properly executed procedure and a good result, the patient is
still unsatisfied because he does not accept his new body
N. Scuderi et al.
image. It can happen that the malpractice claim is started for
purely economic purposes and looking for damage indem-
nity, but otherwise the problem is most probably a psycho-
logical one and originates from the lack of comprehension of
the true motives that force the subject towards surgery on the
part of the surgeon. From a theoretical point of view, we can
say that a mistake was made in such a case, with the surgeon
imprudently rushing the patient into the operating room,
omitting the proper evaluation of the psychological aspects
of the problem in connection with the procedure. Anatomical
indication and surgical expertise are major components of
the selection, but they are not enough in performing aesthetic
surgery. The surgical indication is mainly linked to motiva-
tion, in the absence of which the surgeon can be faced with a
failure; it is as if a thoracic surgeon decides to operate on a
lung to remove a neoplasm that at surgery, or even worse
after the pneumonectomy, actually does not exist.
5.1 Patients at Risk
There is a group of patients who need to be evaluated with
particular care before proceeding with surgery. We have tried
to explain a few typical situations in order to help identify
these subjects, without taking the psychological features of
their personalities into account.
The following list is based on everyday clinical experi-
ence and collects a few situations likely to expose the sur-
geon to higher risks of being sued for medical malpractice. A
few surgical errors are elucidated, all of them capable of
bringing about medical-legal problems.
5.2 Minimal Deformity
When a patient has disproportionate concern for or cannot
accurately and concisely state what “the thing is that is both-
ering him” then the surgeon should ask himself if the alleged
deformity is actually the real problem. Seven to fifteen per
cent of patients who seek cosmetic surgery suffer from body
dysmorphic disorder (BDD) and will experience no improve-
ment in symptoms following surgery, even if the operation
has been performed well and the result is excellent. It is
important to ascertain the degree of improvement imagined
by the patient. The surgeon has a much more realistic image
in mind and the two may not coincide.
5.3 Depression
Patients with depressive illness are easy to recognize. Signs
and symptoms of depressive illness include sleeplessness,
weight loss, lack of concentration, anxiety and psychomotor
Indications, Psychological Issues and Selection of Patients in Aesthetic Surgery
retardation (slowed down activity); but it is important to
learn more. Is the patient’s way of life a reaction to a recent
event or is it a chronic condition? Whether to operate or not
on patients with situational depression is not clear; if the pro-
posed intervention is one of the ways in which the patient is
attempting to rebuild a damaged life, it may prove a suitable
solution. Be wary of patients who believe that an operation
will cure their depression. These subjects should be referred
to a psychologist.
5.4 Life Crises
Patients in the middle of a life crisis such as the loss of a job,
loss of a loved one, divorce or termination of psychotherapy
should be told frankly that the psychological and physical
burdens of an operation will prove too much for them, and
that the operation will not resolve the cause of their emo-
tional turmoil. Such patients have to be visited at intervals,
until is evident that they are emotionally stable.
5.5 Patients in Psychotherapy
A large proportion of patients in psychotherapy request aes-
thetic surgery without having discussed the matter with their
therapist. Obtaining the approval of the therapist before
embarking on surgery is mandatory. Active substance abus-
ers, patients with major depression and schizophrenic
patients should never be considered for aesthetic surgery.
5.6 Hostile Patients
It is always useful to draw patients out about their previ-
ous medical and surgical experiences. If tales of evil or
incompetent doctors are elicited, it is unlikely that the sur-
geon will satisfy the patient’s surgical and psychological
needs. A patient’s hostility will be amplified due to peri-
operative psychological stress, and the surgical experi-
ence will be an unpleasant one for both the patient and the
surgeon. Conversely, if a demanding patient provokes
hostility in the surgeon or other personnel, it may be dif-
ficult to form a relationship without becoming aggressive
towards the patient.
5.7 Communication Difficulties
There is a group of patients who are on an entirely different
wavelength from any surgeon; risks simply cannot be
explained, nor can any idea of the outcome be conveyed to
them. Such patients complain that if they had known there
31
would be a scar, they would never have undergone surgery.
Since the common denominator of litigation is not poor
results but poor communication, even with properly moti-
vated patients, the physician-patient relationship can be
destroyed by the perception that the doctor did not care.
Patients have selective hearing. Explanations should be for-
mulated with diagrams, and in clearly understandable terms
and using metaphors whenever possible.
5.8 Male Patients
All male patients, particularly men requesting rhinoplasty
who are immature or those with a recent concern regarding
their nose, should be evaluated with care. Men make up less
than 10 % of those seeking aesthetic surgery and many men
have serious psychological problems, including sexual iden-
tification issues. The surgeon should be aware that recalci-
trant dissatisfaction may follow an operation on a male
patient. On the other hand, male facelift patients seem more
stable and have a much smoother postoperative course than
female patients have. Beware of the older patient with a new
concern in the appearance of his nose or of the younger
patient who fits the acronym SIMON (Single, Male,
Immature and Overly Narcissistic). The latter will almost
uniformly be unhappy and angry postoperatively.
5.9 Perfectionists
The individual who is perfectionistic about a surgical result
will usually be disappointed, since wound healing is not
always completely predictable. The individual who comes in
with pictures, drawings and exact specifications of what he
or she wants has little or no insight regarding the realities of
cosmetic surgery. As a rule of thumb, fussy patients should
be rejected; they may have body dysmorphic disorder and
they may never be satisfied even with the results of an excel-
lent operation (Fig. 1).
5.10 Secretive or Immature Patients
Patients who show a suspicious degree of guilt over a surgi-
cal procedure by insisting on the need for secrecy are trou-
blesome. Although age does not have a relationship to
maturity in all cases, young patients may have unrealistic
expectations regarding surgical results. Studies have shown
that undergoing surgery for a romantic partner is associated
with a poor outcome. Refuse to perform the surgery if the
immediate family is not in agreement or if communication
with family members fails. Carefully evaluate the level of
maturity in young cosmetic surgery candidates.
32
Fig. 1 Drawing by male patient outlining the changes he wanted to his
face and what procedures should be done
5.11 Indecisive Patients
The patient who cancels operating dates or who is in obvious
conflict about having a surgical procedure should be allowed
to bow out. The patient may not even realize that he or she is
ambivalent about the proposed operation; they may always
return a year or two later. The importance of motivation in
relation to the postoperative result is well established. A
patient who asks the doctor whether they should have the
procedure done should be encouraged to think about it fur-
ther or not have it done at all.
5.12 “Special” Patients
Patients do better if treated according to the physician’s rou-
tine that is known and has proven successful. Exceptions for
“special” patients may lead to trouble. By complying with a
patient’s request for a different management routine, the
physician can reinforce the patient’s misconception of real-
ity. When complications occur, they may be more difficult to
N. Scuderi et al.
accept because the surgical relationship has been distorted.
Individuals who make a constant effort to impress the
surgeon with their stature or who suggest that a good result
will bring many referrals are difficult to satisfy.
5.13 Hidden Desires
There may be a critical discrepancy between what the patient
asks for and what he or she really wants. The surgeon may be
dealing with high hopes and elevated expectations that even a
careful preoperative discussion may fail to detect. Conversely,
surgeons are not beyond scrutiny; the decision to operate
should be made purely for medical reasons and not for finan-
cial considerations or ego. If a procedure requires a skill that
the surgeon does not possess, the surgeon should refer the
patient elsewhere. Many cases which end in litigation are due
to inadequately trained or improperly motivated physicians.
5.14 Improper Planning
Although it is true that poor preoperative or postoperative
management can ruin a good operation, a bad operation can
only infrequently be transformed into a good one through
postoperative attention. When the surgeon carries out the
procedure in the operating room, it should not be for the first
time, and the operation should have been performed in the
mind’s eye ahead of time. Without careful thought and tech-
nique, it is easy for the minor case to become a major one.
Sutures may be revised until the desired result is achieved,
because an operation which looks only fair in the O.R. may
look worse in the office.
5.15 Payment in Advance
Experience has shown that full payment in advance for cos-
metic surgical procedures will make final results look better.
Caution should be exercised regarding acceptation of patients
and their money for surgery at the first visit. Only after the
patient has gone home, thought about what has been said and
returned at no additional cost for a second office visit should
he or she be allowed to schedule surgery.
5.16 Guaranteeing Results
The aesthetic surgeon who guarantees results may be either
inexperienced or dishonest. Careful consideration should be
given to showing patient photographs to cosmetic surgery
Indications, Psychological Issues and Selection of Patients in Aesthetic Surgery
candidates, which the courts interpret as “expressed war-
ranty”. Unless you show pictures of poor and average results
along with the good ones, you are essentially saying “This is
the kind of work I do; therefore, this is what you can expect”.
5.17 The “Iron Surgeon”
The overworked or unhealthy surgeon may do the patient
considerable harm. The fact that a patient is the third facelift
of the day for an over-committed sleep-deprived surgeon
may strengthen the ego but weaken performance and dimin-
ish the patient’s result. Although inconvenient, patients will
usually appreciate the surgeon’s admission that he is “too
tired” that day to give their best result; there are few second
chances in surgical practice.
5.18 Managing the Undesirable Result
If a patient complains legitimately about a postoperative
deformity, it deserves a surgeon’s full attention and respect.
Pretending the problem does not exist or minimizing it will
anger the patient and more importantly over time will distort
the surgeon’s judgement and perception. Eventually that sur-
geon will accept the unacceptable. The best response is to
admit that the patient is correct in his observation and to
focus on rectifying the situation if possible.
5.19 Blaming the Patient
Because our egos are involved in our work, an instinctive
reaction is to blame the patient, just as the ancient ruler killed
the messenger who brought bad news. Patients spend good
time and money for their procedures; they may feel angry or
ashamed when something goes wrong (particularly if they
felt uneasy undergoing surgery in the first place). Increasing
a patient’s guilt may increase their hostility. The patient
wants the security of knowing someone is in control and that
someone should be the physician.
5.20 Being Distant or Unavailable
Understandably, surgeons would like to run away from their
bad results, but no professional should do that. The best
approach is hand-holding via frequent telephone calls and
office visits. The patient will feel better knowing that the sur-
geon is sympathetic and emphatic. There will be less hostil-
ity because the patient will not feel abandoned or helpless.
33
For certain patients, the “hot line” should always be open:
giving your cell phone number may actually decrease the
number of phone calls to the office.
5.21 Failure to Structure a Treatment Plan
Adversity is much harder to bear when there is ambiguity;
therefore a treatment plan should be outlined for patients
with postoperative complications. Even if the plan involves
waiting, it should be clearly communicated with the patient.
An outside consultation with a colleague may be useful to
reinforce a treatment plan when there is a complication, for
example, waiting until a patient’s scars have matured before
performing revisional surgery.
5.22 Unreasonable Fees
Although an attorney might advise that secondary proce-
dures done by the original surgeon should be charged to the
patient, the surgeon should exercise common sense. Should
a carpenter who did not perform the work properly charge to
fix the problem? Even if the surgeon is not at fault, the patient
will feel that he or she is responsible. Anger over revisional
surgical fees may bring a lawsuit. Treat the patient, satisfied
or dissatisfied, as you would want to be treated.
5.23 Failure to Refer
To get another opinion can be of help for both the surgeon
and the patient and it is advisable to communicate to the
referring doctor and to the primary physician any complica-
tion. A predicament may arise if a patient asks another sur-
geon to perform revisional surgery. Occasionally, the patient
will not want to pay the second surgeon’s consultation fee
(let alone the surgical fee) because of the original “mistake”.
In that situation, it is better for the surgeon to offer to pay the
consultant’s office fee, if applicable.
5.24 Lack of Follow-Up
No operation is over until the patient is discharged from the
surgeon’s care. The operation is only part of the sequence in
the care of aesthetic surgical patient. Most surgeons prefer
operating over attending to the postoperative care of their
patients; however, a surgeon may learn very little and may
wind up with dissatisfied patients unless he or she is willing to
follow patients for 1 or 2 years after any aesthetic procedure.
34
6 A Critical Analysis of the Psychology
and Plastic Surgery Relation
Literature
Are there “patient types” or forms of psychopathology that
serve as contraindication to cosmetic surgery? What is the
likelihood of a psychological change following cosmetic sur-
gery? Research has not fully answered these questions and a
new direction for psychological investigation focuses on the
psychology of appearance and specifically on issues of body
image in cosmetic surgery patients.
Individuals pursue cosmetic surgery because they are
unhappy with some aspect of their appearance. Patients (and
surgeons) implicitly assume that a physical change can lead
to positive psychological change; in this regard cosmetic
surgery can function in a manner similar to a psychological
intervention. As described in the Introduction, formal psy-
chiatric evaluation of cosmetic surgery patients first began to
appear in the medical literature in the late 1940s, conducted
primarily by psychiatrists working from a psychoanalytic
perspective. Within this theory, appearance-related con-
cerns typically were interpreted as symbolic displacements
of intra-psychic conflicts. The majority of patients were
described as highly neurotic or narcissistic. Postoperative
psychiatric outcomes generally were described as positive.
More recent investigations have shed the psychoanalytic
orientation, but early studies set the agenda for the majority of
subsequent work. Most often, cosmetic patients have been
described by the presence or absence of diagnosable psycho-
pathology, which was thought to assist surgeons in screening
out severely disturbed individuals. Researchers have used two
primary methods to investigate psychopathology among
patients: the clinical interview and standardized testing. These
approaches have yielded diametrically opposed findings.
6.1 Individual Interview Studies
Although most interview studies are similar in that they
report a high degree of psychopathology in prospective
patients, they share common methodological shortcomings
which raise questions about their validity. In most cases,
interviews are not standardized. The nature of the interview
was frequently not described and uniform diagnostic criteria
as reported in the DSM-IV manual were not applied. The
majority of published investigations do not include a control
group, making it impossible to determine if the reported
level of psychological disturbance was greater than found in
the general population or in patients presenting with other
surgical problems. Such reports reflect assessors’ biases:
interviews were not blind to either the nature of the patient
population or the purpose of the study. Pre-existing belief or
N. Scuderi et al.
theoretical assumption held by psychodynamically trained
interviewers may have affected the questions asked and
interpretation of the responses.
6.2 Standardized Assessments
In contrast to the findings from individual clinical inter-
views, initial studies using standardized testing found
prospective patients to be relatively free of psychopathol-
ogy. Research using standardized tests has shown no psy-
chopathology or only a modest degree, including aesthetic
surgery patients using the California Personality Inventory,
Brief Symptom Inventory, Eysneck Personality Inventory,
Minnesota Multiphasic Personality Inventory, Crown-Crisp
Experimental Index and the Beck Depression Inventory.
Surgeons have also been interested in psychological
changes following surgery, but there have been few such stud-
ies. Interview-based individual studies have produced incon-
sistent findings: early investigations reported transient anxiety
or depression vs. decreases in psychopathology. Only a few
postoperative investigations used standardized testing, show-
ing no postoperative change in psychological symptoms vs.
improvement in anxiety, depression or obsessiveness.
Therefore, literature reports of rampant preoperative psy-
chological disturbances in cosmetic surgery patients are at
odds with standardized testing as well as with the experi-
ences of practicing plastic surgeons. To conclude that indi-
viduals requesting cosmetic surgery are no different from the
general population, as suggested by the results of standard-
ized testing, does not make intuitive sense.
6.3 Body Image Research
The pursuit of cosmetic surgery demonstrates an interest in
the focus on physical appearance. Research has consistently
demonstrated the importance of physical appearance and
preferential treatment in virtually every situation examined
to date. In society, appearance matters, and cosmetic sur-
gery patients may receive a greater deal of their self-esteem
from their appearance. Body image is seen as a multifaceted
construct encompassing thoughts, behaviours and feelings
involving the body and is thought to be critical to our under-
standing of the psychology of cosmetic surgery. Body image
dissatisfaction is widespread, with recent surveys suggesting
that a majority of Americans are dissatisfied with their appear-
ance, referred to as a “normative discontent”. Dissatisfaction
merges into psychopathology as thoughts about the appear-
ance take on greater significance and behaviour is signifi-
cantly affected by the concerns. At its most extreme, body
image disturbances are found in DSM-IV: body dysmorphic
Indications, Psychological Issues and Selection of Patients in Aesthetic Surgery
disorder (BDD) is defined as preoccupation with the defect in
appearance that is either imagined or, if slight, leads to mark-
edly excessive concern. Perceptual inaccuracy is part of the
defining criteria, as are extreme negative value judgements
of the appearance and obsessive preoccupation with the body
feature. Most patients engage in repetitive behaviours, includ-
ing checking, examining or “camouflaging” the offending
appearance feature. The most common areas of the body for
concern are the skin, fatty areas and the nose. Clinically and
experimentally, it has been estimated that 7–15 % of cosmetic
surgery patients have body dysmorphic disorder. The char-
acteristics of patients with body dysmorphic disorder who
seek cosmetic surgery may include patients with the “mini-
mal deformity” or the “insatiable” cosmetic surgery patient.
Patients with BDD may have no improvement or a worsening
of symptoms following plastic surgery or may go on to focus
on a new appearance features. The most appropriate treat-
ment is psychiatric [4].
Measurement techniques now exist to explore the degree
of body image dissatisfaction in cosmetic surgery patients,
including the Multidimensional Body-Self Relations
Questionnaire, the Body Dysmorphic Questionnaire and the
Modified Yale-Brown Obsessive-Compulsive Scale. These
measures can be used preoperatively to screen patients with
potentially excessive or unrealistic body image concerns
who may be inappropriate for surgery (BDD), and can also
be used to assess changes in body image postoperatively.
Although historically patients in plastic surgery have
been categorized into distinct psychological diagnostic cate-
gories, a revolution is currently underway in the field of psy-
chiatry. Recently, it has been recognized that there is a
continuum of different personality disorders and psychiatric
diagnoses. More often than not, a given psychiatric patient
will have manifestations of many different conditions in the
DSM-IV-R. Along with this, there has been the recognition
that many of these conditions have a strong genetic (rather
than environmental) basis. There are several new classes of
drugs which can successfully treat conditions that were for-
mally treated by psychotherapy. It is likely that the diagnos-
tic criteria of the new DSM manuals will be dramatically
different and will change the way that we think about patient
types in plastic surgery.
7 Critical Evaluation of a Case Study:
The Murder of a Plastic Surgeon by
a Dissatisfied Patient
This case study is meant to draw attention to the need for a
thorough and thoughtful personality profile of each patient
and, when in doubt, requesting the help of a psychologist.
Despite the stature that Dr. Vazquez Anon had achieved in
35
the field of aesthetic surgery in Madrid, Spain, he was mur-
dered by a disgruntled patient along with two of his nurses in
March 1977 [3]. In an interview published on the occasion of
his death, Dr. Anon had said that he was considering aban-
doning the field of aesthetic surgery to pursue reconstructive
patients, stating that “the majority of persons who requested
an aesthetic surgical operation needed a psychiatrist rather
than an aesthetic surgeon”. A lesson can be learned from the
details leading up to the murder, which was compiled by Dr.
Ulrich Hinderer from Dr. Anon’s office chart and from the
patient’s primary care doctor’s chart.
The patient was a bachelor aged 45 with a strong family
history of sociopathic and aggressive behaviour. The patient’s
father and two uncles were killed during the Spanish Civil
War; the patient’s sister had two mentally retarded children; a
first cousin married a 16 year old girl and committed suicide,
then another first cousin shot a neighbour whom he thought
responsible for the cousin’s death. A third cousin murdered his
wife and the patient’s uncle shot a business rival with a gun.
The patient said that he had never married because of his nose
and indicated that there was a woman he loved who would
agree to marry him if the appearance of his nose could be
improved. Although the murderer belonged to a family of
wealthy landowners, his intellectual level was below average.
In his village the patient’s family was called “the big noses”
which contributed to the patient’s decision to request aesthetic
surgery. The patient was known to be avaricious and reclusive.
He had few friends, preferring inexpensive prostitutes.
According to Dr. Anon’s records, the patient sought help
because he desired a smaller nose and improved breathing.
Examination revealed a large nose with a marked hump, a
dropped tip, a rightward shift of the nasal dorsum and a left-
ward deviated septum. Dr. Anon noted in the chart that the
patient seemed to be a disturbed patient isolated from soci-
ety, due to feelings regarding his physical deformity, but Dr.
Anon did not request a psychologist’s referral. After surgery,
the people in his village still referred to the patient as “big
nose” and made remarks regarding the surgical procedure,
which made the patient upset.
The patient sought a revisional operation although the
result from the first operation would be considered good. The
patient insisted on being re-examined a second time by Dr.
Anon before the second operation, but was prevented by his
nurses, who mocked the patient as “a clumsy villager”.
Finally, the patient was granted another appointment.
Examination before the second procedure revealed a nose
which deviated slightly to the left, with a left-sided protru-
sion of the base of the columella due to the nasal spine. In the
chart Dr. Anon referred to the “unjustified psychological
stress of the patient”. The result of the secondary procedure
was considered satisfactory by Dr. Anon, who refused to see
the patient again after the routine 1-week postoperative
36
check. Several months later, on the morning of the murders,
the patient wanted to see Dr. Anon. First, he gave a false
identity, and then was caught loitering around the operating
room, trying to force the entry. Although Dr. Anon’s clinic
staff had not informed the doctor that the patient had already
tried to see him during the morning and had tried to break
into the operating room, they finally allowed him into Dr.
Anon’s office, where he promptly committed the murders.
After escaping to his car, the patient crashed while driving at
high speed and died of internal injuries.
In summary, Dr. Anon’s assassin was a social outcast with
paranoid tendencies and an alarming family history undergo-
ing a high-risk procedure. Although the surgeon documented
many “red flags” preoperatively, he failed to take action.
Despite a good result, the patient’s care was handled poorly
by the physician and his staff. This patient’s frustrations
increased, intensifying his aggression, which was finally
directed against the medical team.
On a practical level, refusal to see a dissatisfied patient is
a very serious mistake. A plastic surgeon has probably never
N. Scuderi et al.
lived who enjoyed seeing dissatisfied patients. This reaction
should be overcome, and these patients should be seen fre-
quently. The case of Dr. Anon also points out the dangers of
an overprotective staff.
Dr. Hinderer felt that the mistake in this case was not fail-
ing “to request a deeper psychological study” but in operat-
ing on the patient at all. Any aesthetic plastic surgeon should
be able to recognize psychopathology as grave as that exhib-
ited by Dr. Vazquez Anon’s patient.
References
1. Goin JM, Goin MK (1981) Changing the body: psychological
effects of plastic surgery. Williams & Wilkins, Baltimore
2. Goldwyn RM (1991) The patient and the plastic surgeon, 2nd edn.
Little, Brown & Co, Boston
3. Hindererer UT (1978) Dr. Vazquez Anon’s last lesson. Aesthetic
Plast Surg 2:375–382
4. Sarwer DB, Pertschuk MJ, Wadden TA et al (2006) Psychological
aspects of reconstructive and cosmetic plastic surgery. Lippincott
Williams & Wilkins, Philadelphia
 How to Manage an Aesthetic
Surgery Practice
Karen Evind
Plastic surgery is a fascinating field, not just for the surgeon,
but for the physician’s ancillary staff as well. It is one of the
few medical disciplines that can incorporate all ages in its
demographic. In addition, most plastic surgery practices are
not entirely aesthetic as reconstructive surgery continues to
play a significant role. It then becomes a requirement of the
practice manager to be able to manage the staff in order to
deal with this diverse patient population.
Because most aesthetic surgery practices are single- or
two-surgeon practices this chapter will speak to the single-
surgeon aesthetic practice model as this is where I have
honed my skills as a practice manager.
Managing an aesthetic surgical practice is a challenge. In
order to be successful the physician must be able to place
trust in the practice manager and to that end, hiring the right
person is crucial and it is not as easy as it seems. In observing
medical offices I have found that many physicians do not
place a high enough priority on their personnel. Your spouse,
sibling or college-bound child is most likely not the best per-
son to “help out” in your office.
You want to hire people to work for you who share a com-
mon goal – to make your practice successful. Your staff rep-
resents you – do not expect anything less from them that you
would expect from yourself. You want to have a practice that
maintains a sense of integrity both in medicine and in busi-
ness. As physicians you are required to manage everything in
the operating theater but you should not have to do the same
in your office. In surgery you rely on an anesthesiologist and
a scrub nurse and the same should be done in your office,
rely on your practice manager. You can be aware of the work-
ings of the office without having to micro-manage every
decision and this is where hiring the right person will benefit
you in the long run.
The following sections outline what I believe to be the nec-
essary tools in order to run a successful aesthetic surgery
K. Evind
Toth Plastic Surgery, San Francisco, CA, USA
e-mail: kevind@btothmd.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_4
practice and is based on my 30 years’ experience in being in
charge of, what I hope others see as, a successful plastic surgery
practice. This is meant to be used as a framework to build your
own practice in order to avoid having to “reinvent the wheel.”
1 Office Personnel
One thing that we are always being complimented on by the
patients in Dr. Toth’s practice is that he has had very minimal
turnover in personnel in the 30 years he has been in practice.
Make no mistake, this is important to patients. They want con-
sistency. They come to you because of your reputation for hav-
ing an attention to detail in the operating room and when you
have long standing employees they see it as an extra bonus.
The patients see this as unique – that your office is special –
that you are doing something right to be able to hold on to
employees because almost every other doctor’s office they
visit seems to have a revolving door with their employees.
How do you hire the correct people for your practice and
then keep them as employees once you have hired them? It
requires thoughtfulness and patience on your part. You have
to be willing to take the time to hire the people who will
complement your practice and in turn show them the same
respect that you would to any of your physician colleagues.
Your patients will know the difference and your employees
will feel that they are an integral part of your practice.
2 Practice Manager
Make some decisions prior to interviewing. How do you see
your practice? You need to know what you want your prac-
tice to look like. Your practice will evolve over time; how-
ever, you should know what you want. Write it down. Prior
to interviewing have a list of things you absolutely will not
negotiate as well as a list of things you are willing to
negotiate. I have found that if you compromise on those
things that are most important to you, you may end up
37
38
resenting the person for it. Be clear. Let the person you are
interviewing know what is important to you.
It is a common mistake to think that you can hire your
Practice Manager as a part-time employee. When you are
just starting out and your resources are limited, you need to
have a presence in the office on a full-time basis. Initially,
your Practice Manager will be the person you will rely on to
do everything. That’s okay. You want to have someone who
will be (and wants to be) a longstanding employee and who
knows all aspects of your practice.
Do you need someone who is familiar with how a medical
office should run? Yes. Does that person initially have to
know the ins and outs of plastic surgery? No. You want to
hire someone who is intelligent and who has the ability and
is willing to learn about the remarkable world of plastic sur-
gery. By hiring the right person you will be able to teach your
Practice Manager about plastic surgery in general and about
the procedures you do in particular.
When interviewing for this position, first and foremost,
listen to what this person is telling you. I have found that dur-
ing the initial interview most people do not listen – they are
too busy projecting who they either think or want this person
to be. You absolutely should have more than one interview
with the person you want to hire. You will never obtain all of
the information you need or get all of the questions you want
to ask answered in one interview. It does not matter how well
you think the interview is going and you want to hire the
person on the spot. Don’t. You need to meet more than once
with the person who will potentially be running every aspect
of your practice. Many people can be nervous the first time
they meet someone. Everyone wants to project confidence
and that is difficult to do during a first meeting. If you think
you have found the right person consider having the Practice
Manager from a trusted colleague’s established practice also
interview the prospective candidate. The person who has had
the job for a while can usually assess whether or not some-
one would be an appropriate candidate. Following this, com-
pare notes and see if you are on the right track.
The Practice Manager should be able to oversee all areas of
your business including maintaining the medical records, sur-
gery scheduling, patient appointments, patient education,
accounting, patient billing, etc. Initially, the Practice Manager
will be doing all of these tasks. As your practice becomes
more successful and you hire additional personnel these tasks
may be carried out by someone else, but it will always be the
responsibility of the Practice Manager to oversee them.
3 Clinical Coordinator/Registered Nurse
When starting out in practice it is difficult to justify the
expense of a full-time nurse. Consideration should be given
to establishing a working relationship with a registered nurse
K. Evind
who you could hire on an hourly basis to do postoperative
checks on your cosmetic surgery patients, home visits, suture
removal and pre-and postoperative patient education. This
would enable you to create a per diem position with someone
who then could be hired as a full-time employee as your
practice expands. Utilizing the skills of a registered nurse
would free you up to concentrate on doing surgery and main-
taining your practice.
4 Administrative Coordinator
As your practice grows and the work load becomes too much
for your Practice Manager the next logical step is to hire an
Administrative Coordinator to take over many of the day-to-
day clerical tasks. This will allow the Practice Manager to
concentrate on practice building and development as well as
special projects.
5 The Look of the Office
5.1 Waiting Room
You have spent years training to become a plastic surgeon
and now you are faced with opening the doors of your own
private practice. What it looks like is a direct reflection of
you. Your name is on the door. Obviously your personal taste
will be the first thing your patients see. How your office is
decorated will speak to your own preferences and while the
décor can be well-appointed you need to keep in mind that
many of the people who will be visiting your office will be
actual patients. The same waiting room will have to accom-
modate new patients who are there for first time consulta-
tions as well as postoperative patients. Your furniture should
not be so comfortable as to be a challenge for someone to
navigate if they have just had surgery. It has been my obser-
vation that patients enjoy coming into a plastic surgery office
and seeing a comfortable and clean waiting room (Fig. 1) but
they still want to know that this is a medical office. Walking
into a museum-like space filled with expensive antiques gen-
erally does not set the proper tone for patients.
If you have published an article, chapter or book, consider
placing a copy in your waiting room. Patients enjoy seeing
your academic side and I have found that it does not matter
how technical the writing is. A copy of Dr. Toth’s book An
Atlas of Orbitocranial Surgery is in our waiting room and
patients gravitate towards it. The photos in it are very graphic
and yet the patients are fascinated by it. Even if you have
changed directions professionally to now have a completely
aesthetic practice, patients like to see that you are well-
trained and that you have a solid academic foundation.
Consider having a copy of your curriculum vitae bound and
How to Manage an Aesthetic Surgery Practice
Fig. 1 Photo of front office
placed in the waiting room. This will give patients an insight
into your education and scholarly pursuits.
I hope it goes without saying: all magazines in your wait-
ing room should be current. If you have room for six to eight
people in your waiting room, then that is how many maga-
zines should be there – no more. Stacks of outdated maga-
zines are a turn-off to patients. Consider subscribing to art,
decorating or fashion magazines that are not run of the mill.
And all magazines should be in covers which will avoid hav-
ing them look worn. Recycle the magazines at the end of the
month. Free magazines and tabloid-type periodicals have no
place in your office and are usually associated with hair and
nail salons.
I am a firm believer that brochures should not be in the
waiting room. I know many people do not agree with me. Put
them in the examination room and patients will have an
opportunity to look at them there. A patient has made a con-
sultation appointment with you for a specific purpose and
during your consultation other possible procedures may come
up and can be discussed at that time. In my mind, brochures
can look untidy and do not belong in the waiting room.
5.2 Front Office
Your front office area must be cleared of clutter. The proper
amount of storage in your office is essential. Stacks of patient
charts, paper and boxes have no place in your front office.
39
Patients do not want to see it. They are paying for your ser-
vices and they want the same attention to detail that you have
in the operating room to be reflected in your office. If you
have a small space, figure out how to accomplish this.
Patients want to make sure that their private information is
not on display for other patients to see. If they can see other
patient’s charts they will assume others are seeing theirs. In
the United States a patient’s privacy is protected under fed-
eral HIPAA regulations and adherence to is mandatory.
5.3 Telephone
In most cases your patients’ first point of contact with your
practice will be on the telephone. Training your office
employees on the correct way to handle calls is one of the
most important tasks in your practice. Employees need to be
clear and direct when speaking on the telephone. They have
to know what they are talking about. When you first establish
your practice you want to generate business and there is a
tendency to want to see patients at any time. Decide what
days you will be seeing patients and stick to it. It is prefera-
ble to have set times for office hours; that way patients can be
given some parameters regarding their visits. Open ended
times, asking the patient when they want to come in can give
the impression that you don’t have anything else going on.
Also, by having well-defined office hours you and your
office staff can be more efficient. It will also alleviate having
40
to change appointments because you have scheduled surgery.
Because you are a surgeon there will be times when patient
appointments will have to be changed to accommodate an
unplanned surgery but be aware that patients do not tolerate
having their appointments changed on a regular basis, no
matter what the reason, they generally see it as poor time
management.
Voice mail is a sign of the times. Most people dislike it.
We all live with it. Our office is considered somewhat of a
dinosaur because we do not utilize it, we use an answering
service. I would advise you to turn off your voice mail during
regular business hours. If you employ voice mail you must
be conscious of the recorded message. A long, rambling
message is a turn off. Aesthetic patients are paying top dollar
for your services and calling your office to then be trans-
ferred to voice mail “jail” is not appealing. Minimize your
use of voice mail and use the options module to efficiently
direct your patients to properly route the call. All voice mail
messages should be returned the same day during regular
business hours and the next day if the message is left after
close of business. Patients who feel that they are being
ignored will go elsewhere with their business.
It is important to remember that patients in the office can
hear your employees talking on the telephone. They are lis-
tening to these interactions. It goes without saying that
employees should always be discrete and courteous on the
telephone. Employees’ personal calls should be kept to a
minimum at all times, especially in front of the patients.
Patients do not want to hear a negotiation between a parent
and child, husband and wife, car mechanic, etc. There is no
place for it in the office setting. Of course, there will be times
when this is unavoidable and a telephone in another part of
the office, out of hearing distance from any patients, should
be used. In addition, it is a good general policy that employee
cell phones should be turned off during business hours.
5.4 Examination Rooms
All examination rooms need to be clean and free of clutter.
You are a surgeon – patients want to know that cleanliness is
tantamount in your practice. Believe me, if the examination
rooms are not spotless the patient may make the assumption
that the operating room won’t be either.
If you use a laptop computer to show patients before and
after photographs, make sure that those files are closed
between patients. Never leave photographs on the computer
screen when you leave the examination room. All instruments
should be removed from the examination room before you
leave it. This will alleviate the potential for the patient to be
harmed by a sharp or contaminated instrument. Never leave a
patient’s chart in the examination room. This may sound rudi-
mentary but I cannot stress the importance of having a routine
K. Evind
for every patient. This will insure that you and the patient are
protected. Once a patient leaves the examination room, one of
your office staff should go in and check to make sure that
everything is in order. Bringing another patient into an exami-
nation room and cleaning it up in front of them is not good
form. Patients do not want to see the remnants of your previ-
ous consultation. They want to know that you respect them
and that will be reflected in presenting them with an orderly
room to wait for the doctor. It is during that time – that they
are in the examination room before you come in – that they
have a chance to look around and see if your attention to
detail is reflected in every aspect of your practice.
5.5 Business/Administrative Office
If you are new in private practice you may not have the lux-
ury of space. Your business office and your front office may
in fact be combined. Regardless of the size of your office you
will need to have a place separate from the other patients
where business can be discussed. An examination room is
not optimal and it is a mistake for you, the physician, to dis-
cuss finances with your patients. This will combine “church
and state” – not a good idea. You will be doing the surgery
and it is important that you take care of the medical compo-
nent of the practice and leave the business end to your
Practice Manager.
5.6 Consultation/Physician’s Office
Conduct all of your consultations in your office. It is more
welcoming to the patient. The first time a patient sees you
should not be in an examination room. Your private office
should be a true reflection of you – a bookcase with profes-
sional texts as well as your personal tastes in literature gives
patients an instant “read” on who you are, even before meet-
ing with you. Do you have a hobby that you enjoy; perhaps
you play a musical instrument? Those can be reflected in the
artwork or objects that are displayed. Your private office is
the appropriate place for personal photographs that may
include your family, travel and colleagues. This can person-
alize the patient’s experience and the patient can feel that
they have a sense of who you are as a person.
5.7 Discussing Finances with Patients
You and your Practice Manager should have a worksheet
(Fig. 2) that lists your cosmetic procedures and the costs
associated with them. There are always exceptions to these
expenses; however, this will be an excellent guideline for
your Practice Manager when discussing finances with your
How to Manage an Aesthetic Surgery Practice 41

Onorari per la Chirurgia Estetica

OPERATING OPERATING
SURGEON ROOM ANESTHESIA SURGEON ROOM ANESTHESIA

Face/neck/forehead/eyes/laser SOOF
Face/neck/forehead/eyes SOOF/coronal
Face/neck/forehead SOOF/coronal/neck
Face/neck/eyes SOOF/coronal/neck/eyes
Face/neck
Face/eyes Rhinoplasty (external only)
Face/upper OR lower eyes Rhinoplasty/septoplasty
Forehead w/U/L eyes Nasal tip refinement
Forehead/lower eyes
Forehead Malar augmentation (incl implants)

Eyes (upper AND lower)

Submalar augmentation (incl implants)
Eyes (upper OR lower)
Chin augmentation (incl implant)
Laserbrasion

*full face Breast augmentation

*perioral OR periorbital Cost of saline implants

*perioral and periorbital Cost of silicone gel implants

Lip augmentation w/auto tissue Breast reduction

Lip augmentation w/Alloderm Assistant surgeon

Otoplasty Reduction mastopexy

Abdominoplasty (major) Augmentation mastopexy

Assistant surgeon Cost of saline implants

Addominoplastica Cost of silicone gel implants

Abdominoplasty w/SAL (major) Mastopexy

Abdominoplasty w/SAL
Mini-abdominoplasty Suction-assisted lipectomy

Mini-abdominoplasty w/SAL *abdomen

*flanks

Thigh lift *thighs (outer)

*thighs (inner)

Botox *knees

Dermal filler (per tube) *buttocks

TCA peel

Fig. 2 Aesthetic surgery fee worksheet

patients and financial discussions with patients should
always be done by the Practice Manager. You as the physi-
cian should not be in negotiations with the patient as to what
your charges are. Most patients, at some point in the consul-
tation, ask “What is this going to cost?” and it helps to delin-
eate the roles in the office by letting the patient know that
following their consultation they will meet with the Practice
Manager to discuss finances. In certain circumstances,
should you decide that you want to extend a professional
courtesy to a patient, saying that in front of the Practice
Manager and the patient may be fitting but the actual finan-
cial discussion should be left up to your office staff.
The costs of surgery are discussed with the patient follow-
ing the consultation with Dr. Toth before the patient leaves
our office. We give the patient a statement (Fig. 3) outlining
the costs involved for the surgery that they are inquiring
about and it includes our payment policy. Our payment pol-
icy states that payment in full is required 2 weeks prior to
surgery. There is rarely an exception to this. We do not
require a “deposit” in order to hold a surgery date because
we have found that this can become a complex issue for
some patients. We have always relied on the “simpler is bet-
ter” tenant when dealing with patient financial issues. Our
office accepts cash, personal checks and credit cards. We are
not involved in any monthly financing and we do not assist
patients with any credit forms – it is best to let the patient
obtain their own financing if that is their choice. Entering
into a financial agreement with a third party on behalf of the
patient can be time consuming and usually involves a deep
discount to the physician. If using a credit card, we have the
patient sign a credit card agreement (Fig. 4) that states if the
surgery is cancelled there will be a fee that reflects the costs
charged to our office by the bank for processing of the charge
and refund. The actual dollar amount is filled in and the
patient authorizes this with their signature. If a patient has
paid for surgery with a credit card and then cancels the
42 K. Evind

xxxxxxx, M.D.
A Professional Corporation
Plastic & Reconstructive Surgery
2100 Webster Street, Suite 424
San Francisco, CA 94115
Phone: (415) 923-3008 Fax: (415) 923-3846

Date:

Patient:

Statement for proposed services

$ Name of procedure
Operating room charges
$ Total amount due to xxxxx, M.D.
Payment accepted via cash, bank check, personal check,
VISA, MasterCard or American Express.

Anesthesiologist
$ Total amount due to xxx
Payment accepted via bank check, personal check,
VISA or MasterCard.

$ Nursing care (one night)

$ Hotel xxx (one night)

All fees quoted in this statement are due 14 days prior to surgery.

Costs not included in the above charges: An examination by your personal

physician, blood tests and an EKG are required prior to surgery to clear you for
surgery. You will be required to have prescriptions filled prior to surgery for
you to take following surgery.

Any questions regarding this statement should be directed to:

xxxxxx, Practice Manager.

Fig. 3 Proposed statement of services

surgery, the patient is refunded the charged amount less the
bank fee. There is no reason you should have to absorb costs
for a transaction that will never result in income for your
practice. If a patient pays by personal check and then cancels
the surgery a full refund is returned to the patient once the
bank has assured us the check has cleared.
A simple financial agreement with the patient makes for a
less stressful interaction. A straight forward approach to
finances allows the patient to pursue surgery knowing what
is expected of them and that in turn lets you and the patient
concentrate on a good aesthetic result.
6 Preparing the Patient for Surgery
Once the patient has decided on a surgery date it is time for
your office staff to make all of the arrangements so the
patient ultimately ends up on the operating room table. We
begin with the use of a surgery scheduling sheet (Fig. 5) that
will keep track of all appointments (blood work, history and
physical, EKG, etc.) and all of the paperwork associated with
the patient’s upcoming surgery. The surgery scheduling sheet
is a useful tool for everyone in the office to be able to refer
to. In addition, design pre- and postoperative templates and
How to Manage an Aesthetic Surgery Practice 43

xxxxxxxxx, M.D. - PREPAYMENT FORM

CREDIT CARD AUTHORIZATION REQUEST
Fax completed form to the office of xxxxxxx, M.D. xxx-xxx-xxxx

PATIENT NAME DOB: TELEPHONE

STREET ADDRESS CITY/STATE/ZIP

SURGEON xxxxxxxxxxx, M.D. DATE OF SURGERY:

FACILITY

CHARGES FOR xxxxxxxxxxx,

. M.D.

TOTAL AMOUNT DUE AMOUNT INCLUDES THE OPERATING ROOM CHARGES YES NO

PROCEDURE (S)

DR. xxxx FEE IS SEPARATE FROM THOSE OF THE ANESTHESIOLOGIST.

THE AMOUNT LISTED ABOVE APPLIES ONLY TO THE PROCEDURES & OPERATING ROOM CHARGES LISTED ON THIS FORM.

PAYMENT OPTIONS & INSTRUCTIONS:

PREPAYMENT OF DR. xxxxxx’S FEE & THE OPERATING ROOM CHARGES ARE REQUIRED PRIOR TO SURGERY.
FAILURE TO DO SO CAN RESULT IN CANCELATION OF YOUR SURGERY.

VISA/MASTERCARD/AMERICAN EXPRESS
Required 14 days prior to surgery (your account will be charged 14 days prior to surgery)
Personal Check Required 14 days prior to surgery (your check will be deposited 14 days prior to surgery)

Make checks payable to: xxxxxxxx, M.D.

PLEASE CIRCLE APPROPRIATE CARD: VISA MASTERCARD AMERICAN EXPRESS

AMOUNT CARDHOLDER NAME (AS SHOWN ON CARD – PLEASE PRINT)

CREDIT CARD ACCOUNT NUMBER

EXPIRATION DATE 3 DIGIT SECURITY CODE (LISTED ON BACK OF CARD)

ADDRESS WHERE CREDIT CARD STATEMENT IS SENT

I AGREE TO PAY THE ABOVE TOTAL AMOUNT ACCORDING TO THE CARD ISSUER AGREEMENT
I FURTHER UNDERSTAND THAT IF THIS PAYMENT IS REFUNDED DUE TO CANCELLATION OF SURGERY BY ME
THIS CREDIT CARD WILL BE REFUNDED THE AMOUNT THAT WAS ORIGINALLY CHARGED MINUS
$ (THE NON-REFUNDABLE SURGERY DEPOSIT FEE)

SIGNATURE OF AUTHORIZED PERSON DATE

Questions regarding this form should be directed to: xxxxxx, Practice Manager at (xxx) xxx-xxxx.
Fig. 4 Credit card authorization
44 K. Evind

SURGERY SCHEDULING REQUEST

HOME:
PATIENT NAME: DOB: CELL:
WORK:

ANESTHESIA: LOCAL GENERAL MAAC IV SEDATION BLOCK

OPERATION:

# HOURS: PLACE OF SERVICE:

OFFICE SDSU 23 HR STAY AM ADMIT DAY BEFORE # DAYS IN HOSPITAL

DATE OF SURGERY: TIME: CONF W/ DATE: CONF #

ANESTHESIOLOGIST: CONFIRMED DATE

OVERNIGHT NURSE: CONFIRMED DATE

RECOVERY NURSE: CONFIRMED DATE:

HOTEL CONF W/ DATE: RESERVATION CONF#

SPECIAL EQUIPMENT NEEDED:

PATIENT CONFIRMED SURGERY: PRE-POST OP INSTRUCTIONS SENT TO PATIENT:

HOSPITAL RESERVATION FAXED:

H&P DATE: PHYSICIAN: PHONE:

H&P REC’D LABS DRAWN LABS REC’D EKG REC’D

SCHIRMER’S REC’D MAMMOGRAM PLACE/DATE: MAMMOGRAM REC’D

OTHER:

PHARMACY: LOCATION: PHONE:________________________

ALLERGIES:: PT WILL PICK UP MEDS ON: RX CALLED IN DATE:

NOTES:

OTHER:

Fig. 5 Surgery scheduling sheet

How to Manage an Aesthetic Surgery Practice 45

Date
Patient Name
Address

Dear Ms.:

The following is information you will need regarding your surgery:

SURGERY DATE:
SURGERY TIME:

Please arrive at our office by 7:15 am on the morning of surgery.

1. You will need to have a preoperative history and physical examination by your primary care to clear
you for general anesthesia. The attached form must be completed by your doctor and returned to our
office prior to your surgery. Please call our office with the date and time of this appointment. In
addition, you will need to have an EKG.

2. Preoperative blood tests are required. The request for these tests are included. You can have your
blood drawn in the laboratory of your choice.

3. Pre- and post-operative instructions and anesthesia evaluation form are enclosed. Sign and return the
appropriate forms in the envelope provided.

4. Please our office with the name and phone number of the pharmacy of your choice. You will need to
take postoperative medication and Dr. xxxx requires that you have these prescriptions filled prior to
your surgery because you will need them when you return home from our office.

5. xxxx, R.N. is the nurse will be taking care of you at the Hotel xxxx. She will be picking you up from our
office and administer your post-operative care at the hotel from 5:00 pm on the day of surgery until
6:00 am the morning after surgery. Dr. xxxx requires that an adult be at the hotel from 6:00 am and
accompany you home. He also requires that an adult care for you for the first 24 hours following
discharge from the hotel.

6. The Hotel xxxx is located just five blocks from Dr.Toth’s office at the corner of xxxx and xxxx Streets.
You can obtain information about the hotel at www.webaddressofhotel.com. A reservation has been
made in your name for two nights: (include dates) at the guaranteed rate of $xxx.00 per night.You
will need to call the hotel at (xxx) xxx-xxxx to secure this reservation with your credit card
information. Please refer to confirmation #xxxxx. The hotel requires that you present your credit card
at the time you check in. Please tell the person who will be taking you home that check out time is
11:00 am.

If you have any questions regarding this, please do not hesitate to call.

Sincerely,

Xxxxxxx
Practice Manager
Fig. 6 Sample patient letter
46
have them in your computer to individualize and to suit the
needs of the particular patient. At least 4–6 weeks prior to
surgery a packet of information that includes a cover letter
(Fig. 6) outlining the date, time and place of surgery, the
statement for your services with the due date for payment
clearly stated, consent forms, pre- and postoperative forms
as well as all of the tasks that the patient must complete prior
to surgery should be sent to the patient at least one month
prior to surgery. With email becoming an ever expanding
way to communicate with patients, putting the pre-operative
consents and instructions in a PDF format makes it easy for
the patient to receive the materials from your office.
7 Computer Systems
When looking for an office computer system I have found
that what costs the most is not necessarily the best. Many so-
called medical management systems generally are designed
for multi-specialty practices with complex applications that a
single surgeon office will never use. Obviously, you will want
to be on a network so all computers in the office are linked.
Both Microsoft and Apple have more than adequate software
to accommodate a one or two surgeon office. Scheduling in
Lotus or Outlook can be efficient. These programs are
straightforward and offer the ability to customize them to suit
your practice needs, and Word documents work well to keep
your medical records stored. However, any system used is
only as good as its back-up. An external hard drive and off-
site online back-ups should be utilized in order to maintain
the safety of your records and photographs. Electronic health
records (EHR) systems are becoming more the norm. Care
should be given to which one is selected. Make sure you are
not paying for more than what you will use.
8 Education and Training of Office
Personnel
Don’t overlook ongoing education and training of your office
personnel. Everyone in the office should be CPR certified.
Encourage your employees to attend Ground Rounds at the
K. Evind
hospital where you are on staff, if the topic is of interest to
them. Plastic surgery journals are a great way to keep your
staff abreast of the current advances in plastic surgery, and
this can be a way to further advance their knowledge of your
specialty.
Monthly meetings should be the mainstay of any medical
practice. Although your office may run efficiently it is rec-
ommended that you have an organized forum to bring up
questions and concerns. Office meetings should always have
an agenda, no matter how informal, so that your staff can
address and speak to specific issues. These meetings can be
an excellent opportunity for your employees to know that
you are engaged in and are responsive to their needs and the
ongoing needs of the office.
Private practice can be a challenging and sometimes a
daunting endeavor. It can also be extremely gratifying and
rewarding. You have had to work for long hours during your
training to become the plastic surgeon you are today and now
you have to continue to work hard to make your practice
successful. The hiring of the right employees who will take
this journey with you and who understand where you are
going will make all of this worthwhile. Developing office
systems that work efficiently will enable you to practice
what you put in all those long hours for – the ability to per-
form surgery knowing that you have a team behind you who
share a common goal, good surgery and good patient care.
On a personal note, I would like to thank Dr. Bryant Toth
who I began working for in 1984 when he came to San
Francisco to start his private practice. He was a young sur-
geon fresh from a Craniofacial Fellowship in Paris and I was
a young (very young) woman who knew nothing about run-
ning a plastic and reconstructive surgery office. This speaks
to the generosity of time and dedication that Dr. Toth has
shown to me as well as to the patients he has served and the
others he has employed. I am grateful that I have been given
this opportunity to share with you the lessons that I have
learned along the way.
 Photography in Plastic Surgery
Maurizio Valeriani and Francesco S. Madonna Terracina
1 Introduction
Visual representation is one of the characterizing features of
the third millennium everyday life. From the very beginning
the art of photography has given its contribution, supporting
man in scientific research, taking on a major role in medicine
and surgery. This concept proves even more valuable in its
application to plastic surgery, a field in which visualization,
study and analysis of the shapes are as necessary as crafts-
manship of the surgical techniques.
Every plastic surgeon should own a photographic archive,
representing his clinical activity, with different objectives
and advantages that can be summarized as follows:
• Patient’s identification
• Preoperative analytic evaluation of the patient
• Comparison between pre- and post-operative conditions
• Medico-legal documentation
• Illustrative material available for scientific publications
and meetings
• More clarity in the relation between the physician and the
patient
The quality of photographic documentation is affected by
various factors, such as the photographer’s skill, the equip-
ment used, the conditions of the environment in which the
photographs are shot and the technique applied.
The firms do not always show sensitivity in understanding
what proves to be more useful for the medical utilizer, as often
commercial objectives are not necessarily oriented towards
scientific interests. Nevertheless, up until recently, existing
systems were complex and costly; it is nowadays possible to
obtain excellent results with widespread equipment, whose
prices are much more accessible than in the past.
M. Valeriani, MD (*) • F.S. Madonna Terracina, MD
U.O.C. di Chirurgia Plastica, Ospedale “San Filippo” Neri,
Rome, Italy
e-mail: mauvale@tin.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_5
Certainly the historical step between 35 mm photographs
and digitalization of the technique was useful for archive col-
lecting and graphic elaboration of the surgical procedures,
maintaining high quality standards.
Due to cost cuts, digital technology has enormously wid-
ened its catchment area; the ever-increasing software sophis-
tication, with more comprehensible languages and a more
simple use, has optimized the relationship between man and
machine.
Nevertheless, in spite of directness, it is convenient to
remember that the machines do not act autonomously; thus,
it is necessary to master the basic technique, preparatory to a
correct setting-out of the procedures.
A faithful visual representation and, thus, a good knowl-
edge of basic principles of photographic art represent an irre-
placeable cultural background that will simplify the craft of
the plastic surgeon, making it exceedingly better.
2 History and Evolution
The first scholar in history to relate light and images was
Aristotle, in the fifth century B.C. Since then, various scien-
tists took an interest in the concept of image and among them
were Leonardo da Vinci, Johann Heinrich Shulze and
Thomas Wedgwood, son of the famous ceramic artist, who is
credited with the creation of the first chemically obtained
image exposed on paper, portraying a leaf, in the years
1790–1791 [1].
The first 40 years of the nineteenth century were character-
ized by the experiments of Joseph N. Niepce and of the French
painter Louis J.M. Daguerre, the creator of “daguerreotype”, a
technique of representation which proved to be of utmost
importance on the way towards modern photography [2].
In 1841, the researcher William Fox Talbot described for
the first time a process called “photographic development”
[2] and in 1870 Louis Ducos du Hauron created the subtrac-
tive method, opening the way to the creation of coloured
images. In the second half of the nineteenth century the
diffusion of photographic magazines took place and portraits
47
48
Fig. 1 Bellows camera from the beginning of the twentieth century
were taken of people of all social levels. Photography was
offering to humans a new point of view on the world and was
changing the people’s sense of selfness and their images,
developing that indissoluble connection to aesthetics and
plastic surgery still lasting nowadays [1].
The popularity of photographic equipment boomed
between 1800 and 1900, leading to the establishment of vari-
ous companies which gave and still give much in the field of
optics and physics, such as Agfa, Carl Zeiss, Leica, Ilford,
Kodak and Nikon (Fig. 1).
In the same years there was the appearance of the first
photographic records taken before and after plastic surgery
procedures:
• Between the years1906 and 1907, the plastic surgeon
Miller from Chicago published two papers containing
photographic pictures of the various surgical incisions
utilized for lower lid blepharoplasty [4].
• In 1911, the German surgeon Kolle published his first text
on Aesthetic Surgery, containing numerous pre- and post-
operative photographic pictures [4].
M. Valeriani and F.S. Madonna Terracina
• In 1912, the Berliner surgeons Eugene and Joseph
Hollander took photographic pictures of the successful
clinical results obtained by infiltrating adipose tissue in a
patient affected by facial lipodistrophy and performing in
the other the first real facelift in the history of surgery [4].
In 1929 the arrival of the flash allowed photographers to
operate in any light condition and in the same year Edwin
Land patented an instant developing film, with whom
Polaroid sold millions of cameras.
In the last 50 years [6] the standard equipment to make
photographic records in Plastic Surgery has been the 35 mm
single lens reflex (SLR) camera.
Since the second half of the twentieth century, in associa-
tion with the constant technological improvement of film
cameras, which became easier to use and automatic, a new
system was developed to download images: the digital sys-
tem, utilizing instead of a film a sensor called Charge-
Coupled Device – CCD [6, 7]. Initially developed for
astronomic photography, this device has flooded the market
due to its low cost, the high quality of its images and the pos-
sibility to archive them in a computer, with great savings of
space and money [5].
In recent years 3D images acquisition systems begun to
circulate, such as lasers and structured light scanners.
These create tridimensional models very true to real life
that allow to perform a great number of volume and sur-
face measurements and to provide the patient reliable post-
operative status estimations. They are extremely useful in
evaluating pre- and post-operative conditions, in the fol-
low-up as well as in devising the surgical strategy [8].
Despite the relatively high economic burden, in the future
the opportunity to build up interactive archives of clinical
pictures and to devise customized prostheses [8] will make
the 3D image acquisition systems the gold standard for
imaging in plastic surgery.
3 Equipment and Photographic
Technique
3.1 Photographic Equipment Features
Two factors condition the huge difference between film and
sensor: the lack of uniformity of available equipment, con-
stant evolution and the “post-production” effect that can be
achieved through digital technology.
The final result of the old slides was determined by differ-
ent factors: the photographer, the emulsion makers and
developing laboratory technicians. Furthermore, a simple
slide projector was sufficient to visualize them.
The photographic equipment, according to standard crite-
ria, was made up of the following:
Photography in Plastic Surgery
Fig. 2 Reflex and compact digital cameras
• A reflex body or SLR (single lens reflex)
• A macro with 60 or 105 mm focal distance
• A ring flash, possibly TTL
• 100 ASA professional films, set for daylight
The reflex body gives the opportunity to exchange optics
and is easy to use, due to the various built-in automatisms.
In addition, what you see through the viewfinder is effec-
tively what you are going to photograph. The two SLR focals
have an optic scheme which allows an enlargement ratio 1:1,
with high resolutive power and maximum contrast. The
105 mm macro maintains the same enlargement ratio, but
acts at a double distance compared to the 60 mm. This is
particularly useful in surgery. Finally, the results guaranteed
by the film in terms of chromatic performance, extremely
important in aesthetics, have always been excellent, because
the producers (Kodak and Fuji) together with the processing
laboratories have always given great importance to the pro-
fessional perspective, ensuring inalterable results in time. In
the past, with the analogic system, differences in chromatism
were not determined by cameras, but by the various films and
their subsequent processing. Even the best films used to lose
their quality in time.
Today, with the digital system, the whole procedure is
directly handled by the photographer himself, from the first
shot up to the final utilization. The best thing would be to set
a track capable of obtaining a uniform visualization of
colours between the original target (patient or anatomical
specimen), the monitor, the projector and the printer.
In comparison to SRL cameras, the new equipment forced
the photographer to change his shooting technique and,
above all, to acquire new notions necessary for the treatment
of acquired data. There are two main categories of digital
cameras: reflex [1] and compact (Fig. 2).
49
Reflex cameras are well known, even if today they have a
sensor and no longer a film. Compact are qualitatively infe-
rior in respect to reflex but nevertheless are highly requested
on the market, mainly because they are easy to carry and
affordable. Obviously these considerations are not sufficient
to establish the advantages of compact digital in respect to
reflex cameras for medical applications, as it is more difficult
with these to follow a scientific technique.
The substitution of an analogic reflex with a digital one
would be more convenient, leaving out compacts. Digital
reflex have various advantages [1]:
(a) Better ergonomics
(b) Interchangeable optics
(c) Built-in TTL flash
(d) More efficient white balance and exposure meter
(e) Larger sensor
(f) Wide availability of accessory items
(g) Field-depth adaptation
The larger sensor and the professional optics of SRL, in
respect to compact cameras, provide high quality images.
Optics are defined professional when the treatment of the
lenses and the setting of optical schemes allow a higher con-
trast and a better resolutive power (higher number of lines
per mm). Automatic focusing is extremely precise and fast
and there is no delay in shooting.
Digital reflex cameras, which we will describe in this section,
are greatly superior; nevertheless, compact cameras are consid-
erably popular because they are practical, lightweight and more
affordable. A few practical hints follow, for a better utilization of
compact digital cameras in plastic surgery imaging.
First of all compact digital cameras have no standard focal
distance, such as the reflex, but utilizing the zoom it is possible
50
to reach focal distances similar to those of reflex optics. Usually
this equivalence is pointed out by the manufacturer directly on
the packaging. For this reason there must always be a distance
of at least 1 m between the camera and the patient: the zoom
will minimize unavoidable distortions. Furthermore, to photo-
graph details it is important to always select the “macro” func-
tion, utilizing the zoom to reach the desired enlargement.
In compact digital cameras the focal spot corresponds to
the frame centre, which is the centre of the image. It is, thus,
necessary to position the area of the image we want to bring
into focus towards the centre of the field. The camera has to
be positioned at the same level of the focused area [9].
It is recommended to set the camera on the “A” function
(Auto), totally automatic, or “P” (Program), which allows opti-
mal automatic diaphragm opening and exposure but, opposed to
“A”, leaves to the photographer the choice of white balance.
To avoid unpredictable shadows while shooting anatomi-
cal images in frontal projection with the integrated flash, the
camera should always be held horizontally. If you are out of
a well-equipped photographic studio and the vertical hold is
essential, the use of an annular flash can solve the problem
and be particularly useful in macro shots.
In compact digital cameras, the integrated flash is often
positioned laterally to the objective; this can cause the appear-
ance of upsetting shadows on the background and inadequate
lighting of the subject that has to be photographed. Using 45°
oblique or lateral projections, a useful trick consists in always
maintaining the integrated flash on the same side of the item to
be photographed [9], even if doing so could mean holding the
camera at a rotation of 180°. For example, while photograph-
ing the right profile of a face, the patient should rotate the head
90° towards the right side of the photographer. In this case, it
is necessary to be sure that the integrated flash is sending out
the light from the right side of the objective.
From a practical point of view, the daily working condi-
tions in which a surgeon shoots his pictures (hospital, office
and operating room) appear to be extremely complex and far
from those present in a well-equipped photographic studio
[9, 10]. Thus, in relation to the equipment available in the
actual environment, it is necessary to create standard patterns
to obtain clear and complete images, reproducible and com-
parable with others of different origins, but obtained accord-
ing to the same principles. Obviously, all this is desirable,
even if difficult to perform; it is, thus, important to strive for
a good level of standardization and comparability, at least for
images concerning the same patient.
3.2 How to Take Photographs of a Patient
The photograph registers details permanently and main-
tains them unaltered in time. A professional approach and a
well-shot photograph will inspire the patient as well as the
surgeon with greater confidence: the latter will work better,
handling high quality informative material in the pre-, intra-
M. Valeriani and F.S. Madonna Terracina
and post-operative period [11, 12]. From the first approach
with the patient, one must pay great attention to informed
consent: before taking any photograph, the patient needs
to be informed and he must sign an informed consent form
related to the taking of photographs and their use for scien-
tific purposes, including projections and publishing [13, 14].
Great attention must be devoted to the patient’s positioning,
clothing, attire and lighting. The photograph must be clear
and must not be distorted by clothes, spectacles, jewellery and
make-up, which are distracting items. The genital area can be
covered up with a small bikini. Long hair should always be
tied back. Experience teaches that a compromise must always
be reached in relation to the site where photographs are to be
shot. Having a specific and comfortable space with a secluded
corner where the patient can undress would be ideal. In this
place it is necessary to observe minimal shooting distances,
marking visual references on the floor. The background must
be neutral, single-coloured, unreflective and devoid of vis-
ible patterns [9]. The preferred colours are usually three: light
green, grey and black. Black is usually not recommended
for dark-skinned subjects. Fabric and paper backgrounds are
commercially available. In case of necessity, it is possible with
the aid of an assistant, to put up a sort of a background utiliz-
ing an operating room drape (white, green or light blue) [9]. In
addition to the background, relevant features to be considered
are light, distance, framing and exposition [1].
3.3 Light
Different varieties of light sources exist and each of them shows
distinctive features. Here is a list of the more widespread.
Tungsten light: light transmitted by incandescent lamps with
colour temperature of 2,926 °C. It is a very hot source,
which emits reddish colour dominants, thus non conform-
ing to reality.
Fluorescent neon light: it has two variants. The first type is
emitted by the common neon lamps utilized to light pro-
fessional environments, reaching a temperature of
3,726 °C with greenish colour dominants. The second
type is represented by high frequency fluorescent lamps,
whose temperature reaches 4,726 °C.
Flash light: it has a colour temperature ranging between 5,226
and 5,726 °C and is emitted by camera flashes. This light is
easily transportable, extremely powerful but scarcely con-
trollable and can easily generate unwanted shadows.
Choosing the more suitable type of light is extremely
important to avoid unwanted colour dominants. Light must
be delivered from two different sources, preferably daylight
(5,226 °C), positioned at 45° to the subject; there must be no
interferences either from artificial room or natural light.
Shooting in the operating room makes a lot of difference,
as the environment is very unique and the light is of mixed
Photography in Plastic Surgery
600 mm
4°
200 mm 12°
105 mm 23°
50 mm 46°
28 mm 75°
15 mm 110 mm
Fig. 3 View angle variations related to the focal length of the lens
nature, coming partly from the scialytic lamp and partly
from the neon lights. For operative field details, it is advis-
able to use a macro (100 mm) objective, matched with an
annular macro flash. Before shooting, the scialytic lamp
must be moved or switched off, to prevent the appearance of
the disturbing cone of light in the centre of the pictures,
which creates great contrast with the low lighting of the
image margins. On the contrary, for wider fields, an objective
giving a larger angle (60 mm) is appropriate.
3.4 Distance and Objectives
The reflex body allows to exchange the optics and to obtain
a correct vision through the viewfinder. The larger the focal
distance of the selected objective, the lesser the width of the
visual field corner (Fig. 3). Specifically, considering that the
focal distance of the human eye [9] is around 50 mm,
the objective to be utilized must have a focal distance of
around 100 mm for details and 60 mm for wider fields. This
is due to the fact that at a distance of 2–3 m we still have a
correct perspective, without anatomical distortions [14]. The
51
f/1.4 f/5.6
f/2 f/8
f/2.8 f/11
f/4 f/16
Fig. 4 For optimal focusing, diaphragmatic aperture should be kept at
a minimum
so-called macro should be utilized for details. They have two
relevant features: a high resolutive power, to enhance details,
and a built-in scale of enlargement, very useful to maintain
stability and reproducibility of the images.
For image-correct focusing, it is useful to remember that
a wide opening of the diaphragm corresponds to a lesser field
depth and, thus, all the areas of the picture not included in the
selected focal spot will appear completely out of focus. On
the contrary, if the diaphragm is opened minimally, the image
will result rather sharp even in its edges. The use of the
“macro” function amplifies this characteristic (Fig. 4).
3.5 Exposition and White Balance
In relation to light exposure, it is possible to rely on the camera
automatic setting, whose exposure meter is set on the Kodak
18 % mean grey. For a correct chromatic result, it is conve-
nient to utilize the white balance “auto” setting found in digital
52 M. Valeriani and F.S. Madonna Terracina

Light temperature

10.000 k

9.000 k
Kelvin (k)

8.000 k

7.000 k

6.000 k

Daylight film

5.000 k

4.000 k

Tungsten film

3.000 k

Fig. 6 The digital camera grid consents us to respect Francoforte’s

plane more precisely while taking pictures of the patient’s face
2.000 k

Fig. 5 Colour temperature to detect, for example, differences in cutaneous pigmentation

cameras. The colour of the light reflected by an object depends
not only on the object colour, but also on the colour of the light
itself. The human brain is able to recognize the colour and
adapt itself, balancing chromatic differences, but the digital
camera cannot, because the white produced by different light-
ing sources is different. Therefore, using this function it is pos-
sible to set colour in relation to the light source, and so it will
appear in the photograph as our eyes see it.
It is important to operate light sources properly [11] and to
know how to manage the “White Balance” function, which can
be found in all digital reflex cameras. The colour is evaluated in
relation to its temperature, measured in Kelvin degrees. Daylight
referral temperature reaches 5,500 Kelvin degrees (5,226 °C). If
temperature lowers, colours turn warmer, going towards infra-
red; on the contrary, if temperature rises, colours turn colder,
going towards ultraviolet (Fig. 5). This fact proves useful to
compare patient’s images in the course of time (follow up) and
after treatment [1].
WB can be adapted also at a later stage, during post-
production, on the RAW files.
3.6 Framing and Reference Grids
The last technical advice deals with the use of a referenced
focusing viewfinder or the application of a grid on the LCD
viewfinder, in order to maintain your camera in line with the
subject, assuring an optimal framing for the various body
parts (Fig. 6).
In order to produce images [9, 14, 15], particular tech-
niques exist for the various anatomical regions.
3.6.1 Head
All images of the head must include the neck, the hair and
the ears. The background must be in place within the profile
limits. The referenced viewfinder is useful to maintain the
Photography in Plastic Surgery
Fig. 7 Facial profile imaging
subject in the correct position. The camera must be posi-
tioned at the height of the tip of the nose, complying with the
Francoforte or Virchow plane. The handle is oriented verti-
cally. Besides frontal and profile projections, two 45° shots
are required, paying attention to align the tip of the nose with
the margin of the cheek (Fig. 7).
3.6.2 Eyes
The camera must be positioned at the same height of the
eyes, keeping the handle horizontal. The base of the nose and
the eyebrows must be clearly visible; the sequence of the
images must include closed eyes, open eyes and, for the
evaluation of ocular motility, open eyes gazing upwards,
downwards and laterally, on both sides (Fig. 8).
3.6.3 Nose
In addition to frontal and profile images, taken for the face, a
shot from the chin upwards, with the tip of the nose aligned
with the eyebrows, can be useful [9]. Finally, two 45° projec-
tions taken from above have to be added, to highlight mild
deflections of nasal pyramid.
53
Fig. 8 This image has been shot with a medical macro lens, which is
even able to show skin texture clearly
3.6.4 Ears
A frontal shot of the entire face is mandatory, from the top of
the hair to the clavicular plane, as well as a posterior projec-
tion and a lateral detail. The hair must be tied up. The camera
handle must be turned vertically.
3.6.5 Torso
This is one of the most complex areas to photograph. Breast
imaging must include the area between the clavicles and the
ideal plane passing through the iliac crests. It is suggested to
keep the framing point low, assuming the xifoid region as the
central reference; the patient’s arms must be kept down and
then lifted up high, with the hands behind the head as well as
hidden behind the back. The frontal, the 45° and the profile
are the basic projections.
The same technique also applies to the abdomen, with the
image including the pubic region (Fig. 9).
3.6.6 Upper Limbs
A series of pictures has to be taken both in anterior and pos-
terior projections; both limbs must be included, in extended
position, abducted up to the shoulders, as well as flexed and
abducted with the hands in overhead position. Single limb
pictures can be shot, in the corresponding positions and pro-
jections. Anyway, the muscles of the limbs must be as relaxed
as possible. The camera handle must be horizontal.
3.6.7 Lower Limbs
The picture includes the pelvis and extends from the
umbilicus to the feet. In this case it is necessary to pay
attention to the background size, which must include the
total length of the limbs. An anterior projection, a poste-
rior one, two 45° obliques and two profile ones will suf-
fice, always keeping the feet in the same axis of the
shoulders. It is better to take pictures of the subjects either
naked or wearing a small-sized bikini; a raised platform
can be useful (Fig. 10).
54
Fig. 9 Breast imaging, 45° projection
4 Image and Raw File
Diagnostic photography and photometric evaluation must be
considered part of the procedure commonly utilized to
acquire clinical information. It can be used as a teaching aid,
for diagnostic purposes or for scientific presentations: pho-
tography has to be systematically set, according to a fixed
policy; in this way you can assure that pre-, intra- and post-
operative pictures can be carried out and evaluated by any
medical-scientific operator. It is, thus, necessary to define
standards, even if few data are present in literature [10, 11].
From this you can infer the first great difference between the
analogic and the digital system, which shows both pros and
cons: we no longer use the word “photograph”, but we refer
to a picture originating from an original digital file, called
“RAW file”, which is the matrix for that very picture. RAW
files represent digital negatives or rather the registration of
data drawn from the picture in their original numeric pattern,
with no processing by the camera [1]. As a matter of fact
digital cameras are equipped with a sensor instead of a film
[1, 6]. In most cases this sensor is made up of photosensitive
M. Valeriani and F.S. Madonna Terracina
Fig. 10 Lower limbs, posterior projection. A raised platform is utilized
as a support
components (photodetectors) that by means of an analogic/
digital converter turn the incident beam of light into a binary
code. Each photodetector is positioned into a specific pho-
tosite, to which a single pixel (picture element) will corre-
spond in the final image. The more common type of sensor is
called “matrix linked” or more frequently CCD (Charged-
Coupled Device) [7]. The more dots on the matrix, the better
the resolution and the quality of the image. Thus, in RAW
format we register monochromatic raw data deriving from
digitalization of different levels of electric signals, propor-
tional to the intensity of the light beam reaching each photo-
detector of the sensor.
According to theory, white light is obtained adding up
the three primary colours (additive technique) red, green
and blue (RGB method). This technique, also adopted by
the human eye, is utilized by sensors, with appropriate
algorithms or firmware, which are found in the digital cam-
eras. As a matter of fact, most of the sensors include three
kinds of photodetectors: R (red), G (green) and B (blue).
Each photodetector is sensitive to light and can only mea-
sure luminance. A coloured filter in front of the photosite
reproduces the same colour (Bayer colour filter array) [1].
Photography in Plastic Surgery
Every photodetector registers a single colour and the pixel
is a group of data describing the complete chromatic fea-
tures of that peculiar photosite; thus, to obtain a reliable
image of the picture represented in every pixel, it is neces-
sary to gather three different pieces of information on RGB
intensity, including the two other components that the indi-
vidual photosite cannot register. For this reason the file
containing only output digital data from the sensor indi-
vidual photosites (reaching various millions) is called
“raw” (or unprocessed). To obtain a chromatically reliable
image of the registered shot, it is necessary to subsequently
process registered data (a single chromatic component for
each photosite), calculating the two missing chromatic
components through data registered from adjacent pho-
tosites. RGB data obtained in this way (one captured and
two calculated) in correspondence of each photosite pro-
vide chromatic features of every pixel. Thus, the software
has the task of recreating the lacking colours performing a
sort of interpolation: the quality of the final result exclu-
sively depends on the algorithms effectiveness [14].
Once the picture has been created by interpolating data
collected by the various photosites, it has to be made more
usable by zipping it in JPEG or TIFF format, even if a mini-
mal loss of quality will occur [16].
The great advantage of the RAW registration technique is
represented by the fact that through a subsequent file pro-
cessing, it is possible to retrieve data resulting from a non-
optimal adjustment of a few settings (such as exposure, white
balance, contrast, etc.); on the contrary, it is not possible to
compensate for any potentially wrong setting of the photo-
graphic optic (inadequate focusing, wrong depth of field) as
particular features of the image lost by the camera optic can-
not be recovered.
Every brand has its own RAW format, which is unique
and easily recognizable even among cameras of the same
make and model, due to particular features such as the elec-
tronic background noise produced by the activity of the sin-
gle camera or the intrinsic faults of the sensor. Captured
informations are, thus, permanently preserved in the form of
a binary code, making them definitely unalterable. In the
memory of the camera these numeric prints are processed by
highly advanced algorithms, determinant in obtaining a good
final quality. It often happens with professional equipment
that algorithms in use are updated and replaced, increasing
quality and adding new functions to the original camera.
5 Photographic Archive Handling
and Medico-Legal Implications
The handling of a photographic archive and all the aspects
related to data safety and care of the privacy are closely
bound to the diffusion of the digital technique [6, 14, 17].
Using a digital camera, it becomes easy to take numerous
shots, even if the best thing in an effort to save time and disk
55
space would be to take just a few but valuable ones. The use
of post-production (cutting out, darkening/lightening, colour
exchange, etc.) to improve badly shot pictures is not correct;
with a good camera and properly set lights, it is possible to
obtain good quality photographs, ready to be stored in the
RAW format archive. It is advisable to reserve a computer
only for archive purposes, keeping it in good order and clean,
free from internet connections of any kind, always consider-
ing the relative wear and tear of hard disks.
The built-in hard disk should only contain programs and
the operative system, while the photographic archive should
be stored in one or more distinct and independent hard disks.
It is important to use ventilated hard disks, possibly of the
RAID 0.1 type, which allow to simultaneously copy data on
different disks in real time and, in case of failure, to perform
the hot swap of the spoiled disk with a new one.
An adjunctive safety measure consists in performing peri-
odical back up on optical supports such as DVD or Blue Ray
Disks.
It is important to get accustomed to the use of a software
capable of a complete handling of pictures, such as Aperture
by Apple or Lightroom by Adobe, which have the advantage
of handling the whole imaging process, starting from the
acquisition, saving the registered metadata, up to the poten-
tial optimization of copies of imaging files. At that point,
extrapolation as well as selection become extremely simple.
Whatever the utilized program, the best practice is to sort
out the acquired material within the archive, labelling it into
different categories such as medical or surgical procedure,
pathology, patient’s name and date, allowing for a simple
and immediate consultation [14, 17, 18].
In relation to medico-legal aspects, photographic imaging
plays a major role (Fig. 11). There is the objection that respect
to the film, digital pictures are adjustable and, thus, not valid
before the court. The film was considered physically unalter-
able by computer and able to univocally assign the authorship
of a picture to a single frame, which is owned by the photog-
rapher and cannot be reproduced. All this is based on the par-
ticular physical features of the image grain, which generates
an irregular texture unevenly distributed in the different
frames, as if it was a forgery-proof fingerprint [14].
In digital photography, for aspects also in common with
the film, it is, however, possible to claim the authorship
merely showing the original picture and, thus, the RAW file.
The digital picture, although in a more complex form, is the
sum of images captured by any single photodetector in the
sensor, according to the physical features of the sensor itself.
These details are based on the pixel non-uniformity distur-
bance, conditioning an electronic noise distribution pattern
and giving to any single CCD or CMOS sensor individual
and randomized features [13].
In summary, the fact that any single RAW file is unique
and related to a specific camera derives from the impossibil-
ity to build up two exactly identical sensors, even in the case
of two cameras of the same model. Current technology
56
Fig. 11 The picture shows the functionality of the corrugator supercilii
muscle; from the medico-legal point of view, it is important to take
functional shots before treatment, to rule out any damage that might be
related to the surgical technique
makes it possible to identify the precise sensor utilized for
shooting, as well as to compare pictures taken through the
same sensitive unit; this procedure requires great ability and
the use of complex software.
The Nikon company, a well-known digital camera maker,
provides an identification technique putting together a par-
ticular digital function that can be assembled on certain
reflex cameras and a specific software, that can be also
locked by a hardware key. This software is called Nikon
Image Authentication and assures that a single picture
acquired through that camera is an original one, also verify-
ing whether the picture has been touched up or not.
A new entry, for example, is represented by a new memory
card called WORM (write once, read many), which, after the
registration, is protected from alterations or cancellations.
This knowledge greatly improves the comprehension of
the medico-legal aspects of plastic surgery, considering also
the role of photographic comparison in establishing the so-
called result obligation which actually exists for this medical
branch in various countries.
Despite controversies and interpretations, it is advisable
to have written consent forms at one’s disposal at any time,
to be signed for acceptance by the patient, as well as photo-
graphic and imaging references, quantitatively and qualita-
tively adequate (CT scans, NMR, X-rays, signed photographs,
informed consent forms, etc.).
6 3D and the Future of Photography
Since the beginning of the twentieth century, the classic bidi-
mensional photograph joined and aided plastic surgery in the
pre- and post-operative evaluation of the patients. Nevertheless,
it is evident that a 2D image cannot produce a realistic lifelike
reconstruction of an item that is actually tridimensional.
Stereophotogrammetry enables the reconstruction of tri-
dimensional models from bidimensional images. In the med-
M. Valeriani and F.S. Madonna Terracina
ical field, this technique requires the use of two or even more
CCD cameras, positioned and orientated around the item to
be photographed in a precise reciprocal connection, synchro-
nized to shoot a picture of the same spot, from two slightly
different perspectives at the same moment. The subsequent
computerized processing – by means of specific software –
extracts the tridimensional axial positions in the space of the
corresponding image dots from the coordinates of the
image’s various spots. From these coordinates, the software
reconstructs a 3D model which will be more realistic and
accurate, the greater the number of cameras used simultane-
ously and obviously of the different 2D images captured in
the same instant. Once the tridimensional model is set,
according to the related software, it is possible to perform a
wide range of measurements and complex evaluations,
which are actually impracticable either in the 2D images or
in vivo [19].
3D image-capturing systems, the 3D scanners, are far
more accurate; in recent years they have gradually improved.
At the present time the most interesting devices to be used
in plastic surgery are the laser scanners and the second-
generation structured light scanners. These image-capturing
systems, differently from the ones used previously, develop
tridimensional models from a single scanning, thus utilizing
just one viewpoint; the image acquisition times are in the
order of milliseconds, with an extremely high level of accu-
racy, in the order of a few microns.
3D reconstruction has several advantages, among
which is the possibility to precisely analyze the shape and
the volume of different body segments or parts of those
segments. It is, thus, possible to plan plastic surgery and
other specialized procedures while being well informed
regarding the situation and having the opportunity to
choose, and in the future also to design, customized pros-
thetic implants for single patients. As a matter of fact, the
morphology of these implants is highly consistent with
the receiving site, in agreement with the sought after
result (Fig. 12) [8, 19, 20].
Thanks to appropriate software, tridimensional models
allow the creation of preoperative highly detailed and attrac-
tive graphical processing, capable of offering to the patient
an accurate and realistic idea of the potential result (through
tridimensional morphing), for example, of a prosthetic
implant of the face [8].
Apart from these typically surgical applications, tridi-
mensional scanners enable us to perform measurements
otherwise impossible to carry out with different image acqui-
sition systems.
In this way these allow to detect and standardize new
parameters helpful in defining and pinpointing congenital or
acquired malformative conditions [20] as well as dermato-
logic diseases; furthermore, these allow to test out the impor-
tance of cutaneous aging through the follow-up of the various
aesthetic treatments.
Photography in Plastic Surgery 57

Projector TV
reticule camera

Fig. 13 Structured light scanner setting

Fig. 12 3D image acquisition system

6.1 Main Features of Structured Light

Scanner (Fig. 13)

The structured light optical scanning technique “strip light

projection” allows us to analyze the deviations of a reticule
of parallel lines projected over the examined patient.
If the lines are projected over a rough or already uneven
surface, and/or over a curved subject, the reticule (which is
detected from a different view angle in respect to projection)
appears distorted; the lines sag and their deviation is captured
by a high-resolution video camera creating a tridimensional
image (stereo imaging) and a dotted cloud (3D numerical
matrix of the image) containing all the dimensional data of
the surface examined.
Thus, this technique is based on the image triangulation
principle; the angle is created between the axis of the projec-
tor’s lens and the cameras.
The cutaneous surface can be quantitatively and qualita-
tively measured according to the variations of the angles of
the light beams.
Slight variations in the height of skin surface deflect the
parallel lines of the reticule, with tridimensional effects. The
Fig. 14 Image acquisition
quantitative and qualitative measures of the cutaneous surface
are based on the diversion of the lines beam. A special soft-
ware allows to precisely reconstruct tridimensional images of
the cutaneous surface from bidimensional pictures.
The 3D biometric digital image can be utilized to perform
a series of geometrical surveys and then stored in a database;
it can be retrieved at a later stage and used for comparative
operations (Fig. 14).
All projecting and registering optical equipment, includ-
ing the CCD camera, is built into the scanner body, which is
58
connected via firewire to a PC where the analytic unit is posi-
tioned together with the control functions; the software
allows the simultaneous visualization of both the acquired
real picture and of its processed form.
The following picture shows an example of the irregulari-
ties of the examined surface, obtained through the visualiza-
tion of various pseudo-coloured levels related to different
depths (Fig. 15).
Technical features of the structured light scanner utilized
the following:
• Structured light projector with microscopic mirrors (pat-
ented by Texas Instruments)
• 3D digitalization in real time
• Data capture time: 68 msec for a 3D profile of a cutaneous
area
• Medically unchallengeable light source
• 40 × 30 mm2 field of view
• 640 × 480 spot cloud
• Lateral resolution of 62 μm
• Z-axis resolution of 5 μm (depth measures)
• Colour texture registration (RBG digital texture)
• “Single click” evaluation of all the dimensional parame-
ters of the examined surface
• Measuring field suitable for effective requirements of
cutaneous analysis
• Wirefire connection with an interfaced notebook
• Interactive software for data collection and analysis
Fig. 15 The measurement of any surface irregularity
M. Valeriani and F.S. Madonna Terracina
The scanner can also be utilized for the following:
• In vivo cutaneous measurements and replicas evaluation
• Evaluation of depth, width and topography of wrinkles,
cutaneous lumps, cellulite, etc.
• Topographic analysis of melanomas, neurofibromas, etc.
• Quantitative evaluation of the effectiveness of chemical
peelings
• Estimation of cutaneous excess and of stretch marks
• Comparison of different laser treatment regimens
• Quantitative analysis of palpebral fat bags and of perior-
bital fat
• Dermabrasion/quantitative analysis of wounds and scars/
analysis of surgical revision procedures
• Facelifting/topographic mapping of wide areas of the skin
• Plastic of the lips/volumetric analysis and pre-/post-
surgery comparisons
• Monitoring effective safety of fillers and other cosmetics in use
Measurements functions
• Image acquisition
• 3D digitalization
• Filtering
• 3D measurements
• Database memorization
• Collimation
• Image alignment
Photography in Plastic Surgery 59

• Measurements comparison 6.2 Advantages

• Data processing
• Statistical computation
• Editing report
This analytic software’s full and varied functionality
enables it to recognize the single elements of the images
through the use of pseudo colours in accordance with the
operator’s choice to localize specific areas of interest with
great precision, to calculate width, depth, volume, distribu-
tion, etc., as well as to visualize roughness standards accord-
ing to appropriate charts pinpointed by international
prescriptions (Figs. 16, 17, and 18).
This system has the advantage of using a high-intensity light
in performing meticulous reconstructions, registering very
close distance details (we utilize dots and/or pixels) in a short
length of time.
Images related to measured data are automatically stored
in specific folders previously arranged by the operator, which
will form the patient’s historical database.
Thus, data can be easily retrieved and images can be overlapped
and lined up to perform dimensional comparative evaluations at a
later stage. These enable us to monitor the disease or to verify the
effectiveness of a cutaneous treatment, in order to check the
results obtained by surgery and aesthetic medicine.

Fig. 16 The measurement of width 1,5

and depth of a cutaneous ridge
1,4
13,79
1,3 137,30
mm

1,2

1,1

1,0

0,9
0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0
mm
Fig. 17 The measurement of the ridge radius in a a 1,5
selected area
R108
1,4

1,3
mm

1,2

1,1

1,0

0,9
0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0
mm
b

calculate volume
60
Fig. 18 Auto-alignment of images acquired at subsequent stages
Fig. 19 Colour 3D representation
According to these concepts, structured tridimensional
light scanners represent the ideal tool in objectively evaluat-
ing the results, free from any influence from the observer, the
machine or the environment (Fig. 19).
Current technological developments supply the market
with simpler and more intuitive 3D scanners, whose dimen-
sions are increasingly smaller (portable scanners). To date,
a major limit regarding these instruments has been their
M. Valeriani and F.S. Madonna Terracina
high price, which often induces the single plastic surgeon
to desist, thus missing out on or foregoing undeniable
advantages.
3D image-capturing systems will only become more
widespread in the future if the purchase and handling
expenses are reduced; this is actually a desirable eventuality,
in relation to the great qualitative improvement that this
equipment can provide to plastic surgery.
Photography in Plastic Surgery 61

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 Anaesthesia in Cosmetic Surgery:
European Prospective
Pierangelo Di Marco, Gianni Sampietro,
and Riccardo Bellucci
1 Introduction
In recent years, cosmetic surgery has witnessed widespread
growth and involved every age group of the population. In
turn, this has led to the parallel development of dedicated
structures and anaesthetists.
Similarly, cosmetic surgery anaesthesia techniques have
evolved and diversified, as has occurred in other specialised
areas of surgery, to acquire important characteristics com-
pared to general practice in anaesthesia.
Firstly, whilst one can talk of “minor surgery”, without
wanting to undermine its nobility but simply make reference
to the degree of the physical trauma the operation entails,
there is no such thing as “minor anaesthesia”, and even the
most banal form of anaesthesia, such as local anaesthetic
infiltration, can lead to an outburst of reactions which, if
unrecognised and left untreated, can put the patient’s life at
risk. Furthermore, the patient who resorts to the plastic sur-
geon often requests surgical interventions which do not stem
from the need to treat a specific pathology. Increasingly,
patients are in good health, determined to affront the risks of
surgery in order to improve their physical appearance, self-
esteem and quality of life.
In such situations, it is imperative to limit possible risks to
a minimum and to put the patient in the position to under-
stand, share and accept the procedures put in place to guar-
antee his safety and satisfaction. In this context, the
anaesthetist becomes a reassuring and constructive figure
whose actions are directed at involving the patient in the
P. Di Marco, MD (*) • G. Sampietro, MD
Dipartimento di Scienze Anestesiologiche, Medicina Critica
e Terapia del Dolore, Università di Roma “Sapienza”, Rome, Italy
e-mail: pierangelo.dimarco@uniroma1.it
R. Bellucci, MD
Dipartimento di Anestesia e Rianimazione, Polo Ospedaliero
Rivoli, ASL Torino 3, Turin, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_6
therapeutic choices that are best suited to him and to the suc-
cess of the operation.
It should be noted that, ever more frequently, not only
individuals who are generally in good health, ASA class I–II
(American Society of Anaesthesiology), request cosmetic
surgery, but also patients with systemic pathologies or ill-
nesses of a greater or lesser gravity (ASA class III–IV),
request interventions that are uncorrelated with their pro-
grammed surgery.
All this requires anaesthetists to be particularly aware
when deciding on technique, drugs and preparation of the
patient, who should be placed in the best conditions to reduce
to a minimum any possible risk that could derive from the
potentially dangerous and theoretically avoidable operation.
2 Preoperative Medical Visit
The first step towards patient perioperative safety is the pre-
operative anaesthesiological evaluation. The aim of the ini-
tial anaesthetist-patient encounter, following accurate
anamnesis, is to evaluate patient risk class and to select, in
consideration of patient preference, the most appropriate
form of anaesthesia.
The anaesthetist should request laboratory and instrumen-
tal tests based on patient anamnesis. For many years, a vari-
ety of laboratory tests have been considered routine and
necessary for virtually every type of surgical intervention. It
has been demonstrated in a critical review how this approach
offers no clinical advantage but only increases cost and gen-
erates lengthy surgical time periods for the patient. In fact, at
present, planning a surgical intervention in the ambulatory or
in the outpatient’s department is carried out with methodolo-
gies aimed at increasing efficiency and reducing costs, in the
name of what is referred to as “fast-tracking”.
In this context, a key role is played by choices concerning
pre-medication, anaesthesia techniques, pain therapy, anti-
emetic strategies and fluid regulation therapies in order to
63
64
guarantee success of the procedure which is based on rapid
patient hospitalisation and discharge.
Furthermore, most complications appear to be unpredict-
able and/or unavoidable from routine tests [1]. According to
recent guidelines, preoperative evaluation must be carried out
observing three fundamental steps: anamnesis, objective
examination and, only after and subsequently, targeted and
specific laboratory tests on the anamnesis samples. In 2002,
the ASA (American Society of Anaesthesiologists) published
the standard guidelines, which were approved in 2003 and
confirmed in the latest review in 2008, concerning preopera-
tive consultation and examinations. The American commit-
tee indicates that the tests are useful to identify pathologies
that could influence anaesthesia and to check the state of
already-known pathologies, but confirms the lack of utility of
those routinely performed tests which are not recommended
as a result of specific risk indicators such as: age, pre-existing
illnesses, invasiveness of surgical intervention [2].
The consultation with the anaesthetist is not limited to
evaluating patients’ physical condition, even if this is the pri-
mary objective, others no less important follow.
The patient needs to be adequately informed about the
succession of events prior to entering the operating theatre,
patient anxiety and worry must be reduced and postoperative
care and correct pain therapy planned.
The preoperative consultation, the planning and the
informing patients of the succession of events have proved
more efficient in reducing preoperative patient anxiety than
anxiolytic drugs themselves [3]. Furthermore, states of anxi-
ety have been noted in unprepared and scarcely informed
patients as much as 6 days prior to the operation [4].
The concerns of these patients almost certainly regard the
success of the operation they are about to undergo, but often
the greatest anxieties are caused by the thought of anaesthe-
sia, the fear of “not waking up”, the fear being conscious but
immobilised during the operation and finally to suffer pain.
3 Pain
In cosmetic surgery, the entity of pain stimulation is low as
only the superficial layers of the organism are affected by the
surgical intervention, but the willingness of patients to suffer
even the slightest pain during the operation is often equally
limited.
The winning approach in pain management is found in
initiating therapy prior to commencement of surgery.
Surgery causes tissue damage which provokes the release
of histamine and inflammatory mediators, such as bradyki-
nin, prostaglandins, neurotransmitters and neurotrophin.
The release of mediators activates peripheral nocirecep-
tors, which induce transduction and transmission of nocicep-
tive information to the CNS (central nervous system).
Following the surgical incision, central sensitisation and
P. Di Marco et al.
hyper-stimulation occur which provoke an amplification of
postoperative pain. Impeding the onset of these altered cen-
tral elaboration processes, through multimodal and intensive
antalgic therapy, can determine short- (reduction of postop-
erative pain) and long-term (reduction of chronic postopera-
tive pain) benefits. Preventive analgesia or, as some authors
prefer, pre-emptive, is therapy that prevents or limits central
sensitisation caused by surgical stimulation and inflamma-
tory response and that therefore is not limited only to the
postoperative period but begins before surgery, continues
during the procedure and extends over the postoperative
period, as the inflammatory response can persist well after
surgery and maintain central sensitisation.
The basic universally accepted concept is that preopera-
tive antalgic therapy should be multimodal, based on differ-
ent drugs that act differently and at different levels in an
attempt to block the onset and memory of pain.
A better understanding of the complex physiopathology of
postoperative pain is at the basis of this multidrug approach to
the problem and opioids, non-steroidal anti-inflammatory
drugs, local anaesthetics are the principal weapons available.
3.1 Opioids
The efficiency of these drugs is only limited by the onset of
tolerance or by side effects such as nausea, vomiting, seda-
tion or respiratory depression. They can be administered via
oral, intravenous, intramuscular, subcutaneous, transcutane-
ous and transmucosal routes.
3.2 NSAIDs
Non-steroidal anti-inflammatory drugs (NSAIDs) include
aspirin and paracetamol which exercise their analgesic effect
by inhibiting cyclooxygenase. Other relatively newer drugs
which selectively inhibit the COX2 (Cyclooxygenase2) are
available, provoking minor side effects on the gastric mucous
and platelet aggregation [5]. NSAIDS used independently
determine analgesic efficiency only in slight or moderate
pain, whereas when utilised in association with opioids they
are effective in moderate to severe pain. When administered
orally or via parenteral routes they are a useful component of
the multimodal therapeutic regime described for preventive
analgesia, reducing the request for opioids, diminishing
the side effects and promoting patient recovery [6–8]. When
NSAIDs are employed, the use of paracetamol is also recom-
mended to optimise analgesia and to reduce dosage by taking
advantage of the synergy between the two classes (conscious
sedation) of molecule [9]. Use of these drugs in surgery is
often accompanied by the fear of altered coagulation, even
though many studies have doubted that NSAIDS can have
important effects on coagulation [10–12].
Anaesthesia in Cosmetic Surgery: European Prospective
The perioperative use of low-dose ketamine falls within a
multimodal approach to pain that leads to the reduction of
opioid consumption and therefore a reduction of their side
effects [13, 14].
Pain management is essential in surgery in general but it
is fundamental for success in ambulatory surgery. In fact,
pain is the principal cause of prolonged hospitalisation or
rehospitalisation [15].
4 Anaesthesiological Techniques
Nearly all cosmetic surgery procedures, whenever requested
by the patient and agreed to by the surgeon, can be carried
out in local or local/regional anaesthesia, and nearly all pro-
cedures could be performed with ambulatory anaesthesia.
Given that the primary objective is always the best outcome
for the patient, the anaesthetist can employ many anaesthesio-
logical techniques in cosmetic surgery, subordinating the
choice to best fit patient condition and type of operation.
The patient’s desire, even when it is not necessary, is likely
to be to want to “sleep” and “not see anything” directing the
anaesthetist toward an array of anaesthesiological options that
range from sedation to general anaesthesia. The ASA
(American Society of Anaesthesiologists) has defined the
characteristics of the various levels of sedation (Table 1).
4.1 Minimal Sedation (Anxiolysis)
Sedation is a pharmacologically induced state during which
the patient is able to respond normally to verbal stimulation.
Cognitive capacity and coordination might be reduced but
cardiovascular function and breathing remain unchanged.
4.2 Moderate Sedation/Analgesia
(Conscious Sedation)
Drug-induced reduced consciousness during which the
patient responds to verbal commands, spontaneously or
solicited by light tactile stimulation. No assistance is neces-
sary to maintain airways open and cardiovascular functions
and breathing remain unaltered.
Table 1 ASA, definition of general anaesthesia and analgesia sedation levels (Committee of Origin: Quality Management and Departmental
Administration)
Sedation Sedation moderate/analgesia
Reactivity Normal response to Response to tactile stimulus
verbal stimulus
Unaltered airways Unaltered Not necessary support
Spontaneous ventilation Unaltered Adequate
Cardiac activity Unaltered Often unaltered
Approved by ASA House of Delegates on October 13, 1999, and amended on October 27, 2004
65
4.3 Deep Sedation/Analgesia
A state of depressed consciousness from which the patient is
not re-awakened by light stimulation but by energetic or
painful stimuli. Spontaneous breathing can be depressed and
the airways obstructed and therefore the patient could require
ventilation, whereas cardiovascular function normally
remains unchanged.
4.4 General Anaesthesia
Is a pharmacologically induced loss of consciousness from
which the patient cannot be re-awakened. Breathing is
depressed and ventilation is required. Positive pressure
mechanical ventilation might be necessary. Cardiovascular
function could be depressed.
When we talk of “assisted” ventilation during deep seda-
tion we refer to a series of interventions ranging from head
extension and freeing the upper airways to enable insertion
of medical aids such as an LMA (Laryngeal Mask Airway),
a Combitube, a COPA (Cuffed Oro-Pharyngeal Airway), a
Guedel cannula and a nasal cannula. The use of these aids
does not necessarily transform sedation into general anaes-
thesia but does guarantee free airways and patient
ventilation.
Control of the airways remains the most controversial
aspect of general anaesthesia within which unfortunately the
highest incidence of morbidity and mortality is observed.
The LMA was introduced by Brain in Great Britain
towards the late 1980s, and although it does not guarantee
absolute protection of the airways, it does possess
advantageous qualities such as extreme ease of use, it is non-
invasive, it offers the opportunity to supply a flow of fresh
gases through the connection to the anaesthesia device or to
a source of O2 and to monitor CO2.
Furthermore, its use enables the anaesthetist to use much
lower drug dosages than he would normally administer to the
intubated patient and to use techniques much closer to seda-
tion than to general anaesthesia in order to maintain sponta-
neous breathing, whilst at the same time monitor the quality
and quantity of ventilation through measuring end-tidal CO2.
The success rate of this medical aid has led to the birth of
similar instruments with interesting characteristics such as
Sedation deep/analgesia General anaesthesia
Response to a repeated Absence of response
tactile or painful stimulus
Support potentially Support necessary
necessary
Potentially inadequate Always inadequate
Often unaltered Potentially altered
66
Table 2 Anaesthesia monitoring
Objective
Oxygenation Guarantee blood oxygenation and [O2] in inhaled gases
Ventilation Ensure ventilation
Circulation Ensure adequate haematic circulation
the COPA and Combitube, as well as many others classified
under the general term supraglottic, detailed description of
which goes beyond the aims of this treatise.
The limits, not the absolute contraindications, of all these
aids are found in the fact they do not guarantee the same airway
protection as tracheal intubation and these limits are mani-
fested above all when the patient has to be positioned on his
side or in a prone position on the operating table, or when ele-
vated positive pressure is required for ventilation (obese patient,
thoracic malformations, broncho-pneumo pathologies), and
when operations are particularly lengthy, even if these are rare
circumstances, certainly not frequent in cosmetic surgery.
A further incentive to use these supraglottic aids is that
they do not require the use of muscle relaxants which instead
are employed to facilitate tracheal intubation, thus cosmetic
surgery that is almost exclusively concerned with the body’s
surface area and rarely with the muscular layers does not
derive benefit.
Doing without muscle relaxants in what is often ambula-
tory surgery means reducing necessary postoperative obser-
vation periods, avoiding problems due to residual
curarisation, the ever present risk, with these drugs, of unno-
ticed intraoperative re-awakenings and vomit and nausea
often attributed to muscle-relaxing antidotes (neostigmine)
used when the patient wakes up to guarantee full recovery of
neuromuscular function [16].
With regard to this problem, important especially in
ambulatory cosmetic surgery, the LMA was seen to be effi-
cient in reducing the incidence of nausea and vomit as well
as pharyngodynia which is extremely frequent following tra-
cheal intubation [17, 18].
4.5 Monitored Anaesthesia Care (MAC)
By MAC we intend the combination of local or local/regional
anaesthesia with sedatives and analgesics, administered intra-
venously and accompanied by accurate monitoring as that the
technique encompasses a vast array of clinical conditions
ranging from simple assistance to deep sedation passing
through the intermediate phases ensuring, at the same time, a
preoperative phase, and rapid discharge phase but with qualita-
tive standards equal to those adopted for general anaesthesia.
P. Di Marco et al.
Method
Pulse oxymeter
[O2] detection on anaesthesia device
Capnometry/continuous capnography
Continuous ECG
NIBP (oscillometric bracelet) 5 min.int.
At the basis of monitoring the ASA and SIAARTI (Italian
Anaesthesia, Analgesia and Intensive Therapy Society)
guidelines recommend the use of easy-to-use, reliable and
non-invasive devices, which do not substitute the anaesthe-
tist and the validity of clinical observation and which must
be employed in general anaesthesia in hospitalised patients
and likewise with sedated ambulatory patients and MAC
procedures, ensuring at all times the highest qualitative stan-
dards (Table 2).
The objective is to increase patient comfort whilst notably
reducing costs and hospitalisation times. This is a perfectly
achievable result if dedicated areas with nursing assistance
are created and rigorous and efficient discharge criteria are
adopted contemporarily.
In the ambulatory patient, moderate sedation with analge-
sia, usually using benzodiazepine (Midazolam) and analge-
sics is the principal sedation target in cosmetic surgery. This
level of sedation is considered optimal (according to the Pain
Clinic Manual) when the patient:
1. Maintains consciousness
2. Upper airways remain free
3. Maintains protective reflexes of coughing and swallow-
ing intact
4. Responds to physical and verbal stimulation
5. Is not anxious or worried
6. Feels no pain
7. Manifests only minimum changes in vital parameters
8. Remains cooperative
9. Presents a minimum level of amnesia
10. Returns rapidly to preoperative state
When deep sedation is the desired objective the most fre-
quently employed technique consists of a dose of Midazolam
as pre-medication, followed by variable dosages of Propofol,
which range from 25 to 100 mg/kg/min [19, 20] based on
individual patient clinical response.
Whenever analgesic drugs need to be added to this sub-
stantially hypnotic combination they are normally opioids,
above all remifentanil. These drugs provide sedation/analge-
sic levels that cover a wide range of surgical situations and,
thanks to their synergy, their use in association is close to a
true general anaesthesia.
Anaesthesia in Cosmetic Surgery: European Prospective
4.6 Monitoring the Depth of Anaesthesia
An attempt has been made to develop a system, parallel to
the new anaesthesiological intravenous and non-intravenous
techniques, that offers more guarantees regarding depth of
hypnosis and that investigates anaesthetic response of the
CNS in a more efficient manner compared to what could be
achieved by the measurement of cardiac frequency parame-
ters, arterial pressure and pupil diameters.
The BIS (bi-spectral index) is a simple, bedside, hypnosis
depth monitoring system, which was previously achieved by
observing clinical signs that had little to do with the hypnosis
itself, and which is based on the measurement of surface
cerebral electrical activity using frontally placed electrodes.
The ECG signal is processed through bi-spectral analysis,
frequency and power analysis, and is calculated using an algo-
rithm developed on a statistic model, a BIS index or rather a
numerical value between 0 and 100 that allows for correlation
of sedation and anaesthesia end-points, where 100 equals a
conscious patient and 0 total suppression of cerebral activity,
and where values between 40 and 60 correlate to a state of
abolition of optimal consciousness for surgical anaesthesia.
Although contrasting opinions exist, monitoring is useful
to reduce awareness risks, as has been demonstrated by dif-
ferent important studies [21, 22].
Furthermore, it is useful to identify the correct dosages of
drugs to administer reducing the risk of over- or insufficient
doses, and various authors, using these parameters, have
been able to demonstrate the widespread tendency of intra-
operative overdose with important repercussions on hemo-
dynamic side effects and on the particularly important
reawakening times in elective day hospital or ambulatory
surgery [23–25].
The principal enemies of quick discharge include delayed
reawakening, dizziness, pain, prolonged motor-sensorial
blocks, but also vomit and postoperative nausea (PONV,
postoperative nausea and vomiting).
4.7 PONV
The ability to control postoperative side effects can make the
difference between an efficiently performed ambulatory pro-
cedure and one that requires ordinary hospitalisation.
After pain, vomit represents the second element that can
affect “fast track” discharge. Scientific evidence underlines
how each antiemetic, irrespective of drug class, reduces the
incidence of PONV by a certain degree, therefore, as with
pain, PONV therapy should be multimodal and include drugs
with different activity mechanisms that can act in synergy.
67
The combination with the best cost-efficiency rapport for
routine antiemetic prophylaxis consists of low-dose droperi-
dol (0.5–1 mg) and desametasone (4–8 mg) [26].
The latter appears to facilitate discharge irrespective of its
effects on PONV.
The serotonin inhibitors (5 HT3 antagonists, ondansetron,
dolasetron, granisetron) represent the third class of anti-
emetic drugs.
Their efficiency is equal to that of other aids in PONV
prevention while they seem more efficient in treating the
symptom. This peculiarity and their elevated cost indicate
use in high-risk patients in association with other drugs and
in the treatment of full-blown symptoms [27]. As well as the
pharmacological therapy, ensuring adequate hydration will
reduce nausea [28] and other unpleasant side effects such as
dizziness, sleepiness and thirst in the postoperative phase.
5 Local Anaesthetics
The success of the described techniques depends on the
greater possibility that the anaesthetist has in terms of mole-
cule and technology, but it would be impossible without the
surgeon’s ability to provide efficient deafferentation of the
operating field through infiltrations with local anaesthetic.
Since Niemann extracted cocaine from the cocoa leaf in
1859 the family of local anaesthetics has grown and more
manageable, powerful and less toxic molecules have been
developed. Although the new molecules of local anaesthet-
ics are safer than their predecessors the risks associated
with their use persist. These risks regard their toxicity, dos-
age, speed and site of delivery, absorption, patient clinical
state and finally the physician’s ability to use these
substances.
Their toxicity hits both the CNS, initially with excitatory
effects and then with depressive effects, and the cardiovascu-
lar system giving rise to premature ventricular contraction,
bradycardia, P-R lengthening, and ventricular fibrillation.
Therapy is symptomatic in all cases.
Allergy to amide-anaesthetics is extremely rare [29], and
less than 1 % of cases of supposed anaphylaxis is revealed as
such; indeed they are often confused with vaso-vagal reactions
in anxious patients, or with effects provoked by small intravas-
cular injection of an anaesthetic containing epinephrine.
The administration of epinephrine with the local anaes-
thetic offers increased duration and efficacy of the anaesthe-
sia, reduced haematic loss and a reduction of toxicity as a
result of minor absorption.
It has been demonstrated in many studies that cardiac
frequency and output and systolic pressure are increased by
68
Table 3 Pharmacological interactions with adrenaline
Tricyclic antidepressives Increased sympathomimetic
effects
Non-selective β-blockers Hypertensive and cardiac reactions
General anaesthetics Increased arrhythmogenic
(Halothane) potential
Non-potassium saving diuretics Hypokalemia
Cocaine Arrhythmia and hypertensive
reactions
epinephrine whereas diastolic pressure is reduced and aver-
age pressure remains virtually unchanged [30, 31].
These modifications are not cause for concern in the
healthy patient, but they are in cardiopathic patients and in
those who could present pharmacological interactions with
this vasoconstrictor.
Various studies on humans and animals have shown sig-
nificant undesirable interaction between epinephrine and
tricyclic antidepressants [32], β-blockers, especially non-selec-
tive [33], some halogenated anaesthetics [34], and barbitu-
rates such as Pentothal sodium [35] (Table 3).
Controversy continues and many authors disagree with
regard the adoption of limitations in the use of epinephrine
in local anaesthetic solutions in cardiopaths. Based on his
clinical experience, Little suggested that a local anaesthetic
solution with epinephrine of 1:100,000 can be used safely in
patients on non-selective β-blockers and other studies carried
out on cardiopathic patients suggest that the factor limiting the
use of these drugs in patients with known cardiopathologies
could lie in the maximum dosage of a vasoconstrictor allowed,
that according to authors varies between 20 and 40 mg of solu-
tions containing epinephrine 1:100.000 in relation to the grav-
ity of the cardiocirculatory pathology [36–39].
The risks that derive from excessive caution in the use of
vasoconstrictors should also be considered. Agreement
exists between many authors on the fact that insufficient pain
cover can cause a release of endogenous catecholamine
which could provoke more important effects than those
caused by exogenous epinephrine [39, 40].
If the debate on the toxicity and dosages of epinephrine
concerns all surgery, it becomes particularly heated where
liposuction obtained through tissue tumescence is concerned,
one of the most controversial techniques in recent years and
which crosses paths with the debate on maximum lidocaine
dosages.
This technique foresees the use of ample dosages of local
anaesthetic that are extremely distant from the 7 mg/kg rec-
ommended by the FDA as the upper limit for lidocaine,
which can reach a maximum of 500 mg only in association
with epinephrine.
In contrast with these guidelines, various studies and
common clinical practice have shown that dosages of lido-
caine up to 55 mg/kg, and greater, are safe if a few basic rules
such as a rigorous infiltration technique, correct hydration of
P. Di Marco et al.
the patient, continuous monitoring of vital parameters are
observed, as well as the opportunity to perform, when neces-
sary, immediate vital support therapy [41, 42].
Indeed, the global mortality incidence in liposuction is
influenced by a number of factors, as well as by the toxicity
of elevated dosages of local anaesthetic [43]: inadequate
volemic replacement, underestimated haematic loss, incor-
rect thrombo-embolic prophylaxis, and above all misuse of
vasoconstrictors.
Rao observed that a few deaths were associated with a
low epinephrine dosage (1:2,000,000) which favoured an
excessive absorption of local anaesthetic [44].
Indeed, notable discordance exists on the use of vasocon-
strictors in cardiopathic patients and on the dosages considered
to be safe, for which further randomised prospective studies
using different mixtures of anaesthetics on specific patient pop-
ulations are required. However, the concept that current scien-
tific evidence indicates a wider and less fearful use than that
seen in clinical practice remains valid; in a word, there should
be a valid reason for not using it and not vice versa.
6 Inhaled Anaesthesia
Morton was the first who, using the air, rendered surgical inter-
vention on a neck tumour possible without the patient feeling
pain. It was 16/10/1846 and anaesthesia was taking its first steps.
The components of general anaesthesia are tradition-
ally identified with analgesia, hypnosis, elimination of
autonomous CNS reflexes and in a variable level of mus-
cle relaxation. Halogenated vapours are considered gen-
eral anaesthetics able to produce, depending on dosage,
all the above-mentioned components. Over the years,
the identification of a molecule of low toxicity that offers
rapid induction together with rapid re-awakening has been
searched for. In synthesis, the objective was to produce a low
solubility but high-strength vapour. The two drugs currently
used, Sevorane and Desfluorane, satisfy many of the charac-
teristics an inhaled anaesthetic should possess.
Modern anaesthesia is based on the contemporary use of
different molecules that act in synergy between themselves.
In practice the aim is to reach the clinical objective by reduc-
ing dosages of single drugs, significantly reduce the gravity
and number of side effects.
Barbiturates, benzodiazepines and above all opioids [45–
49] are able to act in synergy with halogenated vapours
reducing MAC (Minimum Alveolar Concentration).
Inhaled anaesthetics act in such a way on the cardio-respiratory
system to determine protective effects on the organism during sur-
gery. The physiopathological effects on the organism of haloge-
nated vapours [50–52] are summarised in Table 4.
An important datum to emerge in recent years highlights
that these anaesthetics can exercise a protective effect on the
myocardium, especially on mechanical function in ischemic
Anaesthesia in Cosmetic Surgery: European Prospective 69

Table 4 Effects of halogenated vapours Table 5 Benzodiazepine use and doses

Respiratory apparatus Cardiocirculatory apparatus Midazolam Diazepam Lorazepam
Reduction pulmonary resistance Global contractility depression Induction 0.05–0.15 mg/kg 0.3–0.5 mg/kg 0.1 mg/kg
(dose-related) Maintenance 0.05 mg/kg or 0.1 mg/kg 0.02 mg/kg
Mucociliary clearance decrease Left ventricle after load reduction 1 μg/kg/min
Reversible phosphatidylcholine Catecholamine sensitisation Sedation 0.5–1 mg 2 mg 0.25 mg
reduction repeatable repeatable repeatable
Vascular resistance slight Slight coronary vasodilation Miller’s Anesthesia 2005
reduction
Pulmonary hypoxic Ischemic preconditioning
vasoconstriction attenuation means some benzodiazepines present prolonged effects,
Tachypnoea Baroreceptor reflex depression such as in the case of Diazepam.
Tidal volume reduction Midazolam, which is used increasingly more in pre-
Reduced response to hypercapnia medication, has much more useful characteristics from an
anaesthesiological point of view, amongst which, strong
damage and reperfusion. The anaesthetic gases appear in fact anterograde and retrograde amnesia, anxiolysis, sedation,
to reduce the extension of the area affected by infarct, con- scarce respiratory depression, scarce hemodynamic impact
serving its integrity during the acute phase [53, 54] and and not to be overlooked, availability of a specific
favouring myocardial recuperation. These factors lead us to antidote.
consider how these agents can truly reduce the risk of periop- The much shorter half-life and the much higher strength
erative ischemic damage [55–62]. of the other benzodiazepines make them suitable for induc-
tion (0.1–0.2 mg/kg) in association with opioids. Clinical
experience indicates that the use of opioids or volatile
anaesthetics as adjuvants, a plasmatic substance sufficient
7 Intravenous Anaesthesia to guarantee hypnosis and perioperative hypnosis and
amnesia [65], is obtained with a 0.05–0.15 bolus mg/kg
Modern intravenous anaesthesia began in 1939 with the (Table 5).
advent of Thiopental, a barbiturate that is still used in clinical
practice today but which is far from that ideal of complete-
ness that we refer to when we think of an anaesthetic that 7.2 Opioids
provides hypnosis, analgesia and muscle relaxation, without
important secondary effects. Fundamental drugs that are used in every phase of anaesthe-
The ideal drug has yet to be synthesised and the different siology from premedication to induction and maintenance
drugs are used in association to obtain the desired effect and extending to postoperative antalgic therapy.
reduce side effects to a minimum. An investigation carried Administration of opioid prior to pain stimulation, rather
out in 1988 highlighted how the use of multiple anaesthetic than during or after, attenuates physiological response to
drugs is associated with minor mortality compared to the use stress, and by interacting in synergy with the other drugs
of a single or two drugs only [63], and many recent studies leads to a marked reduction of perioperative dosages.
have indicated that the characteristics of this technique are Fentanyl, a protagonist of the balanced anaesthesia era,
well suited to ambulatory surgery; in fact, it is easy to imple- owes its fortune to brief onset times, due to its lipophylicity,
ment and is associated with reduced development of nausea notable strength, peak action times achieved within 4 min, all
and vomit compared to inhaled anaesthesia, and does not with much lower cardiovascular effects compared to other
require the use of muscle relaxants. molecules of the same class. Its pK and pD profile render it
Propofol in association with Remifentanil appears to suitable for perioperative use. Induction of the anaesthesia
dominate TIVA (Total intravenous anaesthesia) practice with can be obtained with a load dose (2–6 mg/kg) together with
conventional infusion systems or the TCI (Target Controlled a hypno-inductor and muscle relaxant, while maintenance
Infusion) method [64]. can be achieved through intermittent boluses of 25–50 mg
every 1,530 min, adapting dosages to surgical stimulus inten-
sity and to operation times.
7.1 Benzodiazepines

Act with a central Gaba receptive mechanism and possess 7.3 Morphine
good liposolubility, and it is for this reason that they cross the
haemato-encephalic barrier easily, but this characteristic An old drug such as morphine, given its ability to contrast
along with the low hepatic clearance and active metabolites skeleto-articular and visceral pain, always finds room in the
70
postoperative phase even if its use is often associated with
side effects such as nausea, vomit, sleepiness, negative action
on the sphincters and on intestinal motility.
The postoperative analgesia dose should be calibrated to;
operation type, expected stimulated pain, the patient and his
general condition, and finally the response of the patient to
the anaesthetics as individual responses are wide-ranging.
Generally, in postoperative analgesia, dosages range from
0.03 to 0.15 mg/kg every 4 h for intravenous delivery,
whereas they range from 0.05 to 0.2 mg/kg for subcutaneous
administration. The use of strategic antiemetics enables the
reduction of postoperative nausea and vomit incidence but
the tendency to save on these drugs, as for example the use of
local anaesthetics even during general anaesthesia, or with a
cautious management of postoperative opioids represent
today the most efficient weapon to avoid PONV (Post
Operative Nausea and Vomit).
7.4 Remifentanil
The latest addition to the family, Remifentanil is a very potent
opioid, 250 times more than morphine. Thanks to its pharma-
cokinetic and pharmacodynamic characteristics it is frequently
used in modern-day anaesthesiological practices, from sponta-
neous breathing under sedation to general anaesthesia in opera-
tions of various entity and from sedation in intense therapy to
interventions that require brief intraoperative re-awakenings.
Its profile is in fact of a drug with an extremely short half-
life scarcely sensitive to the context, with a rapid equilibrating
effect to the site of only 1.4 min, no tendency of accumulation
and rapid re-awakening phenomena, thanks to a metabolic
hydrolysis operated by plasmatic and tissue esterase and
finally to rapid renal excretion of the inactive metabolite.
The contest referred to when talking about the drug’s
metabolism is the infusion duration and its relationship with
the halving times of the drug’s plasmatic concentration at
the end of infusion, in this case, it remains brief irrespec-
tive of infusion duration. It is known as a context insensi-
tive drug which in practical terms means that, irrespective
of anaesthesia duration, re-awakening times and functional
recovery of the patient are constant. The drug is prevalently
infused continuously to minimise the onset of side effects
such as bradycardia, hypotension, muscular stiffness which
are dose-dependent effects. The contemporary use of ben-
zodiazepine and the maintenance of adequate blood levels
contribute to limit such side effects [66]. The dosages, purely
indicative and which should be individualised to the single
patient range from 0.05 to 0.1 g/kg/min for sedation to 0.25–
0.48 g/kg/min for general anaesthesia.
In conclusion, the use of this drug is recommended in
situations such as cosmetic surgery, especially if it is ambu-
latory or in day hospital, where the infusion of Remifentanil
P. Di Marco et al.
appears to offer rapid discharge when compared to other
anaesthesiological techniques [67]; furthermore, its side
effects, due principally to its parasympathomimetic activity
and negative chronotropic, are predictable and controllable
[68–70].
7.5 Ketamine
The new stereoisomer of this phencyclidine derivate, and the
knowledge of its peculiar central anti-hyperalgesia activity,
delineates its use today as an optimal co-adjuvant in pain
therapy. The principal target of the drug is the NMDA recep-
tor which is often implicated in acute postoperative pain phe-
nomena, following general anaesthesia, as much as it is in
chronic pain genesis.
Ketamine has shown a significant ability to inhibit central
hyperalgesia, to prevent phenomena of tolerance to opioids
and to reduce postoperative analgesic request [71, 72].
7.6 Propofol
With the introduction in clinical practice of Propofol [73, 74]
in the 1980s we have taken a step closer to the ideal drug.
Propofol offers rapid action, hypnotic and sedative, of easy
titration, ultra brief and does not accumulate, as it also pos-
sesses antiemetic properties.
This drug is an alkylphenolic derivate, highly lipophilic,
that interacts with the GABA receptors, beta sub-unit, main-
taining them in an active state, and with NMDA stimulatory
receptors, promoting inhibition [75, 76].
Its effect is particularly rapid with loss of consciousness
obtained after 30 s following the administration of 1 bolus.
In the case of propofol, prolonged infusions also offer rapid
re-awakenings [77] thanks to an efficient, plasmatic redistri-
bution from the central compartment to a wider, peripheral
one, with low perfusion and inactive sites, and to a rapid
metabolism. It possesses cardiovascular side effects, acts on
peripheral resistance and on cardiac inotropic state causing a
predictable and contrastable reduction of arterial pressure,
with adequate volemic replacement and with a cautious reg-
ulation of the effect [78–80].
Given its pharmacokinetic and pharmacodynamic character-
istics, its use ranges from sedation (25–100 g/kg/min), to induc-
tion (1–2.5 mg/kg), to maintenance (100–200 g/kg/min).
7.7 TIVA/TCI
With the development of ever stronger analgesic and hyp-
notic drugs and with shorter half-lives, and with the develop-
ment of more efficient infusion systems, the opportunity to
Anaesthesia in Cosmetic Surgery: European Prospective 71

substitute a balanced anaesthesia with a totally intravenous
one has become a reality that offers numerous opportunities,
even if, thus far, it does not represent the only choice.
Without the aid of computerised systems, dosages of the
drug are calculated by the anaesthetist based on patient
weight, and are modified based on clinical parameters during
the course of anaesthesia.
Even if this method is not conceptually wrong, it is not pre-
cise as it does not consider the individual pK and pD variables.
The TCI system, a computerised infusion system based
on pharmacokinetic models, bearing in mind the pharmaco-
logical characteristics of the drug used and the patient’s
anthropometric data, calculates the diffusion constants of the
drug between the tissue compartments, clearance and modi-
fies the amount of drug administered over time.
The main advantage of this computerised system is that it
enables stable plasmatic concentrations to be maintained and
offers excellent control of the effects of the drug.
This technique, like the others previously mentioned have
been developed over time to guarantee accuracy of results
and patient safety, and are applied in the continuous search
for the best result in the field of cosmetic surgery where the
precision of surgical techniques and assistance to the patient
are subject to critical review more than ever before.
7.8 Rhinoplasty
Anaesthesiological objectives: patient comfort, peri/postop-
erative analgesia, hemodynamic management of patient
(controlled hypotension), airways management (Table 6).
Additive, reductive mammoplasty and mastopexy.
Anaesthesiological objectives: perioperative patient com-
fort (uncomfortable operating positioning, lengthy times,
sub-muscular prosthesis position), peri/postoperative anal-
gesia, hemodynamic management (Table 7).
7.9 Lifting
Anaesthesiological objectives: patient comfort with regard lengthy
operating times, optimal hemodynamic control (Table 8).

Table 6 Rhinoplasty and anaesthesiological techniques

Advantages Disadvantages
General anaesthesia Easy and rapid execution PONV phenomena and trembling
(inhalatory/intraovenous) Patient unconscious and immobile Patient uncollaborative on reawakening
Good control of peri/postoperative pain
Local anaesthesia by infiltration Low pharmacological impact Painful infiltrations
Reduced costs Patient discomfort
Collaborative patient Scarce airways control
Rapid discharge
General anaesthesia (remifentanil + sevorane) + local Hemodynamic control TIVA TCI infusion systems availability
anaesthesia by infiltration with adr. Patient fully collaborative at reawakening
Good control of peri/postoperative pain
Rapid drug elimination
No PONV
LMA Easy and rapid execution Non-optimal airway control with
Patient unconscious and immobile abundant bleeding
Good peri/postoperative pain control

Table 7 Mastoplasty and anaesthesiological techniques

Balanced general anaesthesia
Local anaesthesia by infiltration
LMA/deep sedation
Remifentanil + Propofol + local infiltrations Excellent hemodynamic control
Advantages Disadvantages
Easy and rapid execution PONV phenomena and trembling
Patient unconscious and immobile Awakenings unforeseeable
Good peri/postoperative pain control Possible hemodynamic oscillations (danger
of postoperative bruising)
No hospitalisation required Patient discomfort
TIVA TCI infusion systems availability
Perioperative comfort
Satisfactory analgesia
Muscle relaxant not required
Foreseeable reawakening
72 P. Di Marco et al.

Table 8 Lifting and anaesthesiological techniques

Balanced general anaesthesia
Local anaesthesia by infiltration
General anaesthesia/deep sedation
Remifentanil + Propofol + local infiltrations
Advantages Disadvantages
Easy and rapid execution PONV phenomena and trembling
Patient unconscious and immobile Awakenings unforeseeable
Good peri/postoperative pain control Possible hemodynamic oscillations (danger
of postoperative bruising)
No hospitalisation required Patient discomfort, especially with total
face lift
Excellent hemodynamic control TIVA TCI infusion systems availability
Perioperative comfort
Satisfactory analgesia
Rapid metabolism drugs even after lengthy
operations

Table 9 Liposuction and anaesthesiological techniques

Balanced general anaesthesia
Local anaesthesia by infiltration tumescence
General anaesthesia/deep sedation LMA
Remifentanil + Propofol + local infiltration
tumescence
Advantages
Easy and rapid execution
Patient unconscious and immobile
Good peri/postoperative pain control
Collaborative patient, no hospitalisation required Patient discomfort, pain during
Excellent control of clinical
parameters (hemodynamic, diuresis,
hematochemical)
Rapid metabolism drugs even after lengthy
operations, good pain control
Disadvantages
PONV phenomena and trembling
Awakenings unforeseeable
Possible hemodynamic oscillations (danger
of postoperative bruising)
infiltrations, possible hemodynamic
oscillations of varying entity
TIVA TCI infusion systems availability

Table 10 Blepharoplasty and anaesthesiological techniques

Balanced general anaesthesia
Local anaesthesia by infiltration
Moderate/deep sedation/LMA
Midazolam/Remifentanil/Propofol
Advantages Disadvantages
Easy and rapid execution Equipped operating room required
Patient unconscious and immobile and hospitalisation plan
Good peri/postoperative pain control
Excellent pain control, rapid execution, no hospitalisation Slight discomfort during infiltration
required, possibility to perform in fully equipped studios of tissues
Excellent pain control, rapid execution, no hospitalisation TIVA TCI infusion systems
required possibility to perform in fully equipped studios, total availability
patient comfort, reduction of spontaneous movements

7.10 Liposuction Acknowledgement We thank Mr Barry Mark Wheaton for his invalu-
able linguistic assistance with this work.
Anaesthesiological objectives: optimal control of clinical
parameters, monitoring of excretion for important liposuc-
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 Anesthesia for the Cosmetic Patient:
An American Perspective
A. Roderick Forbes
1 Introduction
“Primum non nocere”
According to American Society of Plastic Surgeons
(ASPS) statistics, there were 12.1 million cosmetic proce-
dures performed in the United States in 2008, of which
13.8 % were surgical. ASPS member surgeons saw an
increase in surgical procedures of 234 % from 1992 to 2008.
The most commonly performed surgical procedures were
breast augmentation, rhinoplasty, liposuction, blepharo-
plasy, and abdominoplasty [1]. More of these procedures
are being performed in an office setting. The advantages of
office-based surgery (OBS) include personal service, pri-
vacy, ease of scheduling, lowered costs, efficiency and con-
sistency of personnel, and the ability to monitor and
influence infection rates [2].
2 Patient Safety
Despite earlier concerns over safety in the OBS setting [3],
recent reviews have concluded that OBS and outpatient sur-
gery is safe if performed in an accredited facility by Board
Certified surgeons credentialed for the same procedure in a
hospital [4–6].
Factors contributing to a low rate of problems are trained
anesthesia providers, careful patient selection, full preoper-
ative preparation, adequate intraoperative and postoperative
monitoring, and appropriate postoperative care [7]. In light
of this, and in view of the increasing proliferation of OBS,
and attendant office-based anesthesia (OBA), the American
Society of Anesthesiologists (ASA) has recently published
a manual addressing the administration of OBA, stressing
that the standard of care in OBS should equal that of a
hospital [8].
A.R. Forbes, MBChB, FFARCS
Department of Anesthesia, California Pacific Medical Center,
San Francisco, CA, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_7
The manual covers the areas of facility administration,
quality of care, the facility and safety, patient and procedure
selection, perioperative care, monitoring and equipment, and
emergencies and transfers. It emphasizes the importance of
preparedness and planning, in addition to the equipment and
drugs necessary to deal with the unanticipated emergency,
ranging from the difficult airway, to cardiac dysrhythmia or
arrest, to local anesthetic toxicity, anaphylaxis, uncontrolled
bleeding, or malignant hyperthermia. It stresses the impor-
tance of a transfer plan to an alternate care facility should the
patient’s condition warrant it.
3 Patient Selection
Careful patient selection and preparation is vital to the safe
provision of anesthesia and surgery in OBS. Since not all
patients are candidates for OBS [8], the suitability of a par-
ticular patient and procedure should be determined in
advance by discussion between the surgeon and anesthesiol-
ogist. Examples of unsuitable patients might include unsta-
ble patients ASA 3 or greater, or those with recent MI, recent
stroke, cardiomyopathy, uncontrolled hypertension, poorly
controlled diabetes, morbid obesity, MH history, severe
COPD/OSA, or those with pacemaker/AICD [7]. This might
include also a patient with a recognized difficult airway, and
one lacking a responsible adult escort home.
Patients should undergo a complete history and physical,
preferably by their own physician, ahead of surgery, to elicit
their previous and current health, comorbidities, family and
social history, medications, allergies and reactions, and prior
anesthetic exposures and outcomes. The history should
include a systems review. Physical examination would include
general appearance, height, weight, vital signs, and cardio-
pulmonary examination in particular. A sample history and
physical form is given by Iverson [9]. Lab testing would
include EKG in those over 50 [10], or those with cardiac dis-
ease, with further testing dictated by the patient’s medical
condition [9, 11]. Each patient is then assigned an ASA
75
76
Table 1 ASA physical status classification system [12]
P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat
to life
Physical Status (Table 1) [12]. The majority of patients will
be healthy, ASA Class P1 or P2, with a small number being P3,
having a severe systemic disease which is stable. Examples of
patients within these categories by Twersky are given by
Iverson [9]. Such predictors of intraoperative or postoperative
events as hypertension, obesity, smoking, asthma, and gastro-
esophageal reflux can be detected at this point [13], and treat-
ment optimized preoperatively if necessary.
Also at this time patients are assessed for their risk of
thromboembolism and pulmonary embolism, which is the
leading cause of mortality in outpatient surgery, being
responsible for 57 % of the 2.02 deaths per 100,000 proce-
dures reported by Keyes et al. from 2001 to 2006 [6]. The
procedure most frequently associated with death from pul-
monary embolism is abdominoplasty [6]. Attention should
be paid to predisposing factors such as history of contracep-
tive and hormone therapy, history or family history of throm-
bosis or embolism, genetic disposition to clotting disorders,
history of smoking, and edema, swelling, or lower limb
venous insufficiency. Patients can then be classified as low,
moderate, or high risk, based on their risk factors [14]. In
high risk patients, in addition to slight flexion of the knees,
and the use of sequential compression devices (SCDs),
hematology consultation and antithrombotic therapy should
be considered [14–16].
4 General Approach
“Patients have come to expect an almost perfect anesthetic
and surgical experience, with safety and comfort being their
foremost concerns” [17]. Initially the patient’s history and
physical is reviewed by the practice nurse ahead of surgery,
and any concerns raised with the surgeon and/or anesthesiol-
ogist at that time. If necessary, the patient is contacted for
further information, consultation or testing. The anesthesiolo-
gist endeavors to contact each patient before surgery, address
any concerns and allay any anxiety at that time. On the day of
surgery, the patient, appropriately fasting [18], is met by the
anesthesiologist who conducts a preoperative history and
physical in the patient’s room, and discusses the anesthetic
approach and expectations, in addition to the risks involved,
until the patient is satisfied. After the surgical interview, the
patient enters a warm operating room, where the blanket,
sheet, and intravenous fluid have been warmed.
A.R. Forbes
A choice of music is offered. The appropriate monitors, non-
invasive blood pressure, EKG, pulse oximeter, are attached.
An intravenous cannula is inserted after a skin wheal of lido-
caine with a 30G needle. A small dose of midazolam is
administered to allay anxiety. A pillow is positioned under the
knees to flex them slightly, and, for all except those undergo-
ing a short procedure under minimal sedation, sequential
compression devices (SCDs) are applied, and their proper
functioning verified. All pressure points are gel padded and
arms positioned appropriately. The patient’s comfort is veri-
fied prior to proceeding. All patients receive antibiotic pro-
phylaxis, analgesics, and a combination of antiemetics at the
appropriate times. Temperature is monitored and the patient
kept warm throughout. At the conclusion, when awake and
stable, the patient is transferred back to the room accompa-
nied by the anesthesiologist and the nurse who will attend and
continue to monitor her until she is fully recovered and ready
to leave the office. A patient who has undergone rhytidec-
tomy, or abdominoplasty, will commonly be released to a
qualified nurse who will attend her overnight.
5 Anesthetic Approaches
The ASA has described the continuum of depth of sedation
from minimal sedation to general anesthesia, shown in
Table 2 [19]. A variety of anesthetic approaches along this
continuum, in addition to regional and conduction anesthe-
sia, can be employed in the care of aesthetic surgical patients.
5.1 Monitored Anesthesia Care (MAC)
MAC is not a technique, but rather a “specific anesthesia ser-
vice in which an anesthesiologist has been requested to par-
ticipate in the care of a patient undergoing a diagnostic or
therapeutic procedure” [19], commonly to provide a state
ranging from conscious to deep sedation, to supplement
local or regional anesthesia [20]. The benefits of conscious
sedation are quoted as avoidance of cardiopulmonary effects
of general anesthesia, airway injury, postoperative nausea
and vomiting (PONV), and positional nerve injury, and less
risk of deep venous thrombophlebitis [21]. Several agents
have been employed to provide analgesia, relief of anxiety,
amnesia, and optimal safe operating conditions. Those
commonly used are midazolam and propofol for sedation,
anxiolysis, and amnesia, and ketamine, fentanyl, alfentanil,
and remifentanil for analgesia [20]. Frequently these drugs
will have synergistic effects on level of consciousness and
depression of respiration, requiring particular vigilance on
the part of the anesthesiologist [22]. Although surgery is
regularly performed safely with the MAC approach [23, 24],
an analysis of closed claims involving injury associated with
Anesthesia for the Cosmetic Patient: An American Perspective 77

Table 2 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia [19]
Moderate sedation/
analgesia (“Conscious
Minimal sedation/anxiolysis Sedation”) Deep sedation/analgesia General anesthesia
Responsiveness Normal response to verbal Purposefula response to Purposefula response Unarousable even with
stimulation verbal or tactile stimulation following repeated or painful stimulus
painful stimulation
Airway Unaffected No intervention required Intervention may be Intervention often
required required
Spontaneous ventilation Unaffected Adequate May be inadequate Frequently inadequate
Cardiovascular function Unaffected Usually maintained Usually maintained May be impaired
a
Reflex withdrawal from a painful stimulus is NOT considered a purposeful response

MAC revealed that 40 % of claims involved death or serious
injury, a percentage comparable to that of general anesthesia,
with respiratory depression from sedative or opiate drug
being most commonly responsible [25]. The authors consid-
ered nearly half the claims to have been preventable by better
monitoring, carbon dioxide sampling, improved vigilance, or
audible alarms. Underscoring this is the finding in a recent
review of mortality in accredited facilities, which showed
one death only attributed to an intraoperative event, when
propofol, midazolam, and fentanyl were administered with-
out a qualified anesthesia professional in attendance [6].
Further along the continuum of sedation, the combina-
tion propofol-ketamine, described as dissociative anesthesia,
has been reported to result in a low incidence of postopera-
tive nausea and vomiting (PONV), and a reduction in the
need for opioids [26]. A more recent approach in the com-
bination of agents is that of adding dexmedetomidine to a
regimen of propofol, fentanyl, ketamine, and midazolam
[27]. Dexmedetomidine is an α2 adrenergic agonist, which
induces sedation and analgesia when administered as an
infusion, lowering blood pressure and heart rate, reducing
narcotic and sedative requirements, resulting in fewer epi-
sodes of oxygen desturation, and resulting in less antiemetic
and narcotic use postoperatively [27, 28]. Some of the same
agents can be used also in combination to produce total intra-
venous anesthesia (TIVA), predominantly relying on propo-
fol [20], an approach which results in a lowered incidence of
PONV compared to volatile anesthetic agents [29, 30].
5.2 General Anesthesia
In complex, combined, or prolonged procedures, general
anesthesia (GA) confers several advantages, including con-
trol and protection of the airway, and reduction of the risk of
inadvertent patient movement or pain perception, allowing
the surgeon to focus on the operation without distraction.
This can be accomplished at minimal risk to the patient in an
accredited facility with qualified staff [17, 31]. A comparison
of the recovery profiles of propofol, isoflurane, sevoflurane,
and desflurane revealed that, with the exception of a lower
incidence of PONV after propofol, the differences among
agents were small, and the differences in recovery times to
discharge were 5–15 min [30], not likely to be relevant in a
setting where patients remain under observation in the office
for some time. Gupta noted that the concomitant administra-
tion of other drugs may well have negated the advantage in
awakening and recovery of the newer inhaled agents.
5.3 Low Flow Anesthesia
In the office setting, when administering inhaled anesthesia,
a technique utilizing a low fresh gas flow (FGF) offers sev-
eral advantages, chiefly those of less waste of agents, reduc-
ing costs [32], and lowering environmental pollution,
obviating the need for an expensive waste scavenging sys-
tem. The waste anesthetic gas can be removed by a simple
disposable activated charcoal filter [33]. Low flow also
retains heat and moisture in the patient’s airway. Since a low
FGF approach is not commonly utilized in a general hospital-
based practice, it is worthwhile explaining what is entailed.
A detailed discussion is beyond the scope of this chapter, but
may be found by Hendrickx & De Wolf in Modern
Anesthetics [34].
The circle absorber system is the most commonly used
anesthesia breathing circuit. Fresh gases, oxygen, nitrous
oxide and air, start at the rotameters of the anesthesia machine,
then pick up the selected anesthetic vapor, isoflurane, sevoflu-
rane, or desflurane, at a concentration determined by the dial
on the vaporizer. These enter the inspiratory limb of the cir-
cuit as the inspired gases. They are taken up by the lungs dur-
ing induction and maintenance of anesthesia. The expired
gases, a mixture of alveolar gas and dead-space gas from the
airway which has not taken part in gas exchange, are then
directed by one-way valves to the expiratory limb, then to the
breathing bag during spontaneous respiration, or the ventila-
tor bellows during controlled ventilation. Carbon dioxide is
removed by the soda-lime absorber. Excess gas is vented to
the atmosphere, typically through a scavenging system. When
78
the FGF exceeds the patient’s minute volume, i.e., high flow
anesthesia, the inspired concentration will be the same as that
delivered in the FGF, and all the expiratory gas will be vented.
When the FGF is less than the minute ventilation, i.e., low
flow anesthesia, the inspired gas will be a mixture of fresh
and expired gas with a lowered concentration of oxygen and
vapor, from which the expired carbon dioxide has been
removed. When the FGF is lowered to 500 ml/min, approach-
ing the sum of oxygen uptake, around 240 ml/min [35], anes-
thetic uptake, and sampling gas removed by the gas analyzer,
around 200 ml/min, this becomes very low flow (VLF) anes-
thesia. Because at this point the bulk of minute ventilation
now consists of expired gas with a lower oxygen concentra-
tion than that delivered by the anesthesia machine, and
because anesthetic uptake can vary considerably between
patients [36], it is mandatory that the anesthesiologist moni-
tors, and pays close attention to, inspired and alveolar (end-
tidal) concentrations of oxygen and anesthetic agent measured
by the gas analyzer at the patient connection, Y-piece, of the
circuit. Because anesthetic uptake varies with time, being
maximal initially, falling to a slowly decreasing level thereaf-
ter, a higher FGF during induction will be necessary for a few
minutes to establish an adequate alveolar and, hence, brain
concentration before initiation of minimal flow. Various flow
patterns have been developed to achieve a constant concentra-
tion rapidly [37–40].
Although nitrous oxide may be utilized in low flow
anesthesia, it is not adsorbed by the scavenging charcoal
filter, and for this, and its effect on PONV and other com-
plications [41, 42], there are those who question its use [43,
44]. To avoid prolonged exposure to 100 % oxygen, nitro-
gen may be restored to the circuit, by introducing a low
flow of air to the FGF mix, e.g., oxygen 400 ml/min, and air
100 ml/min, which results, at equilibrium, in an inspired
oxygen concentration of 71 % [45]. Because the inspired
concentration of oxygen will be lower than the fresh gas
concentration, close attention must be paid to the measured
inspired oxygen level [45], and vigilance and appropriate
alarms are necessary.
The takeaway from this is that low flow, and very low
flow anesthesia, with the help of recent knowledge and study,
and with accurate and reliable gas analyzers, can be success-
fully utilized in the OBS setting, with considerable benefit.
6 Specific Procedures
6.1 Rhytidectomy
As always, individual practitioners should choose their tech-
nique and approach based on training and experience, and the
particular needs of their patients. For the reasons previously
discussed, and according to the preference of the surgeon,
A.R. Forbes
our approach is to provide general anesthesia, accompa-
nied by infiltration of lidocaine and epinephrine in saline.
We employ a volatile anesthetic, except in patients at very
high risk of PONV. After a premedication of midazolam and
fentanyl, and preoxygenation, fluid replacement is instituted,
and induction accomplished with propofol. Endotracheal
intubation, with a lubricated small diameter endotracheal
tube, is achieved after a small dose of rocuronium, and com-
monly no further muscle relaxant is administered. The posi-
tion of the endotracheal tube is verified, and the tube clearly
marked at the lips, so that it is visible at all times. The eyes
are protected with sterile lubricant, and subsequently cov-
ered with a clear sterile dressing. Ventilation is controlled,
and the initial phase of higher gas flow of oxygen and vola-
tile anesthetic begun. When the end-tidal anesthetic concen-
tration has reached the desired level, very low flow (VLF)
is instituted, and the vaporizer setting adjusted to maintain
the desired level. During this time typically one side of the
brow, face, and neck, as appropriate, will be infiltrated by the
surgeon with a solution of lidocaine 0.2 % and epinephrine
1:250,000 in saline. Any shortfall in the depth of anesthesia
at this point can be augmented by propofol and/or fentanyl.
During this time close attention is paid to blood pressure,
first to guard against hypotension on induction, treated with
a small dose of ephedrine as necessary rather than fluid
challenge [46], and subsequently to lower blood pressure
as necessary to facilitate dissection and minimize bleeding.
A moderate reduction only is sought, to a level above that
defined as controlled hypotension (mean arterial pressure
50–65 mmHg, or 30 % reduction from baseline) [47]. If an
adequate anesthetic level does not achieve this, fentanyl and
labetalol are added as necessary. Since there is no apprecia-
ble third space loss, fluid administration is generally minimal
after replacement of the fasting deficit. The fasting deficit
itself may be less than previously assumed, since intravascu-
lar volume is normal even after an overnight fast [46]. This
approach results in a modest fluid administration, tailored
to the patient’s needs [48], avoiding bladder distension in
shorter procedures. In prolonged procedures a urinary cath-
eter is inserted during anesthesia.
Prior to closure of the first side, the blood pressure is
allowed to rise to preinduction levels, assisted by a small dose
of ephedrine if necessary, so that adequate hemostasis may be
assured. Turning of the head, and infiltration of the second
side, is anticipated with a dose of fentanyl. Infiltration of the
second side at this point will typically result in a total dose of
lidocaine around the recommended limit of 7 mg/kg, although
a recent study showed that doses three times that resulted in
peak plasma lidocaine levels well below 5 mcg/ml [49].
Again, prior to closure of the second side the blood pressure
is allowed to rise. Restoration of neuromuscular function is
confirmed, and spontaneous respiration allowed to resume if
it has not already done so. Then, to facilitate a smooth
Anesthesia for the Cosmetic Patient: An American Perspective
emergence without excitement or coughing, a dose of nar-
cotic is titrated, the anesthetic level allowed to wane, and pro-
pofol administered as small bolus doses or as an infusion until
completion of surgery [50]. Gentle suction of the pharynx is
performed, and the endotracheal tube removed when the
patient responds appropriately to voice. There is a significant
reduction in incidence and severity of coughing at extubation
in patients emerging from propofol compared to sevoflurane
anesthesia [51]. During this time too, labetalol is given as
necessary to forestall or attenuate any rebound hypertension,
a major determinant of postoperative hematoma [52].
6.2 Abdominoplasty
An approach similar to the above is utilized for abdomino-
plasty. No skin infiltration is employed, but a continuous
local anesthetic release device may be employed in post-
operative pain management. Adequate analgesia is assured
prior to awakening. In view of the importance of avoiding
coughing and straining during emergence when the rectus
muscle sheath has been imbricated, the following maneu-
ver may be considered [53], provided the patient is not at
risk of gastroesophageal reflux, and no difficulty with the
airway has been encountered or is anticipated. With the
patient flexed, in the head up position, the stomach and
pharynx are suctioned. With the patient breathing sponta-
neously at an appropriate depth of anesthesia, a laryngeal
mask airway (LMA) is inserted behind the larynx, the cuff
inflated, and the endotracheal tube removed. Subsequent
awakening and removal of the LMA result in fewer respi-
ratory complications than seen with tracheal extubation
alone [53].
6.3 Breast Augmentation/Reduction
Submuscular placement of an implant will require adequate
muscle relaxation to allow stretching and dissection, and an
adequate view to achieve hemostasis in the pocket. If this
cannot be achieved with depth of anesthesia alone, then mus-
cle relaxant may be required. Because of anticipated muscu-
lar pain and spasm, adequate analgesia is administered prior
to a smooth awakening. The simple expedient of instilling
bupivacaine for ten minutes, and subsequent removal through
the drains at closure, has been shown to help in postoperative
pain management in reduction mammaplasty [54].
6.4 Liposuction: “Superwet” Technique
This surgical technique involves the injection, in the ratio
of 1:1 with the anticipated volume of fat to be removed, of
79
a solution containing lidocaine 0.04 %, and epinephrine
1:1,000,000 in saline. This is typically a volume of 2–3 l,
well below the threshold of 5 l considered large volume
liposuction, and within the commonly accepted dose of
35 mg/kg of lidocaine [8]. The procedure is usually neither
extensive nor prolonged, factors cited as presenting a
greater risk of complication, particularly pulmonary
embolus [55]. Commonly it involves truncal liposuction,
with a position change from prone to supine. This can be
accomplished with MAC [24], or GA, but lends itself to
the use of MAC for the flank approach in the supine posi-
tion, with CO2 monitoring per nasal cannula, and with the
level of sedation tailored to allow the patient to cooperate
in the position change to supine. After this the sedation
may be deepened, to GA if necessary and desired, and the
airway secured, for the more extensive anterior approach.
This requires appropriate patient selection, and a thorough
explanation to, and consent from, the patient preopera-
tively. SCDs are utilized throughout, regardless of
approach, in a warm environment, and a warming blanket
applied where possible. Although fat is removed in a 1:1
ratio with the fluid injected, up to 70 % of the injectate will
be absorbed, and blood loss is reported to be around 1 % of
the aspirate volume. Fluid administration under these cir-
cumstances should be at maintenance levels only [56].
7 Postoperative Nausea and Vomiting
In office-based aesthetic surgery, PONV is undesirable
from all points of view, and aggressive preventative mea-
sures are appropriate. Apfel’s simplified score for predic-
tion of risk [57] shows patient risk factors of female
gender, nonsmoker, postoperative requirement for opioids,
and a history of PONV or motion sickness. The corre-
sponding risks of PONV for patients having 0, 1, 2, 3, or 4
of these factors are approximately 10, 20, 40, 60, and
80 %, respectively. Apfel subsequently found that each of
the four interventions, ondansetron, dexamethasone, dro-
peridol, and substitution of propofol and nitrogen for vola-
tile agent and nitrous oxide, was equally successful in
reducing the incidence of PONV in the 24 h after surgery
[58]. Each intervention reduced the risk by 26 %, all
worked independently, and combinations had additive
effects. In lieu of droperidol, which has fallen out of favor,
metoclopramide could be considered [59]. A patient at
moderate risk might receive a combination of two prophy-
lactic antiemetics at the appropriate times, and one at high
risk might receive two or three antiemetics, or a multi-
modal approach including those plus a TIVA of propofol
and low dose ketamine, e.g., to reduce narcotic require-
ments [60]. A comparable multimodal approach, including
anxiolysis and hydration in addition, has come close to
80
eliminating PONV [61]. Rescue therapy, if required, would
then be from a different group from the prophylactics, e.g.,
prochlorperazine or promethazine [60].
8 Special Situations
8.1 Operating Room Fires
The face is the second most common area of the body damaged
by fire in the OR. In a closed claim analysis of injury associated
with MAC, 17 % of claims involved burn injuries to the face
from electrocautery in the presence of supplemental oxygen
[25]. The problem of OR fires was addressed in an ASA
Practice Advisory, which includes an algorithm for pre-
vention and management [62]. For a fire to occur, the classic
triad of components must be present; an ignition source, e.g.,
electrocautery; fuel, e.g., drapes, alcohol prep; and an oxidizer,
e.g., oxygen, nitrous oxide. These conditions are commonly
present in aesthetic facial surgery performed under MAC, with
supplemental nasal oxygen. In addition to the preventive mea-
sures in the algorithm, where the airway is not secured, the con-
centration of oxygen around the face may be reduced in other
ways. One such is the approach described by Taghinia [27],
involving use of dexmedetomidine to minimize respiratory
depression, and hence the need for supplemental oxygen.
Another is to deliver oxygen to the posterior pharynx via a can-
nula inserted through a soft rubber nasopharyngeal tube, which
has been shown to reduce oxygen concentration over the face to
that of ambient air [63].
8.2 Malignant Hyperthermia (MH)
Although every effort should be made to identify a patient at
risk of MH, any site where triggering anesthetics and/or suc-
cinylcholine are administered should be equipped to manage
MH. This means personnel must be ready to diagnose and
treat an episode with the appropriate supplies and drugs, par-
ticularly dantrolene, and have in place an emergency transfer
plan [8]. A current approach to the emergency treatment of
MH can be obtained from MHAUS [64].
8.3 Local Anesthetic Toxicity
Since large volumes and doses of local anesthesia can be
administered in aesthetic surgery, a protocol should be in
place for the treatment of toxicity. Guidelines for the man-
agement of severe local anesthetic toxicity are posted on the
website of the Association of Anaesthetists of Great Britain
and Ireland [65].
A.R. Forbes
8.4 Anaphylaxis
Although rare, anaphylaxis can be catastrophic, presenting
suddenly as cardiovascular collapse and bronchospasm [66].
In the perioperative period where a large number of drugs
are given in a short time, those most commonly involved are
muscle relaxants, latex, and antibiotics, in that order [67].
Management consists in discontinuation of the anesthetic and
drugs and immediate administration of epinephrine [66, 68].
Airway support with 100 % oxygen; intravenous fluid replace-
ment; histamine blockers, both H1 and H2; bronchodilators;
and corticosteroids will also be required. In cases refractory
to epinephrine, norepinephrine, metaraminol, or glucagon are
recommended, and vasopressin may be an alternative 68].
Conclusion
The trend towards office-based procedures in aesthetic
surgery is likely to continue. If attention is paid to proper
patient and procedure selection, careful preoperative eval-
uation, adequate intraoperative and postoperative moni-
toring, and appropriate postoperative care with minimal
pain or nausea, the same techniques of anesthesia that
apply in the hospital may be tailored to the needs of the
patient and procedure in an accredited office setting to
provide a safe and pleasant experience for the aesthetic
surgical patient.
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 Post-operative Pain Therapy
Gabriele Finco, Gian Nicola Aru, and Mario Musu
1 Introduction
“An unpleasant sensorial and emotional experience, associ-
ated with actual or potential tissue damage, or described in
terms of such damage”. This definition by the International
Association for the Study of Pain (IASP) summarises clearly
the multi-dimensional aspect of pain: a discriminative senso-
rial experience always associated with an adverse emotional
connotation, “intrinsically unpleasant” occasionally all-
absorbing and incoercible.
Pain is not only an unpleasant subjective experience, it is
also responsible for numerous physiopathological alterations
and damaging effects that taken together lead to the so-called
stress reaction.
The reflex responses evoked by pain stimulation involve
organs and systems globally, provoking neuroendocrine and
metabolic alterations, such as increased secretion of cata-
bolic hormones and inhibition of anabolic hormones (hyper-
catabolic states). The sympathetic hyperactivity often
associated with this picture is instead at the basis of the nega-
tive effects that can affect the cardiovascular system, includ-
ing a worsening of cardiac insufficiency or an ischemic
event, or the gastrointestinal apparatus, determining visceral
paralysis and nutritional disorders. Also immune system
deficiency and coagulation disorders are found among the
many consequences that can result from stress reaction in a
G. Finco, MD (*)
Dipartimento di Scienze Mediche “M. Aresu”,
Università di Cagliari, Cagliari, Italy
e-mail: gabrielefinco@medicina.unica.it
G.N. Aru, MD
Cattedra di Anestesia, Dipartimento di Scienze Mediche
“M. Aresu”, Università di Cagliari, Cagliari, Italy
M. Musu, MD
Dipartimento di Scienze Mediche “M. Aresu”, Ricercatore
Universitario di Anestesiologia, Università di Cagliari,
Cagliari, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_8
complex and profound disruption of the homeostasis which
is ultimately responsible for lengthening hospitalisation and
for the increase of risk factors.
Even though, thus far, it has not been possible to clearly
demonstrate that adequate analgesic therapies correspond to
a clear improvement in patient outcome, evidence exists on
the negative impact caused by adverse manifestations related
to pain on the patient’s comfort, delayed mobility and finally
post-operational mortality.
Analgesic therapy, which in the past was employed in a
casual and approximate manner, still appears to be over-
looked by physicians today, despite much pharmacological
and technical progress, as well as an improved understanding
of the complex physiopathology of pain.
Thus, the lack of adequate therapeutic protocols and,
above all, of a systematic approach to the treatment of pain
symptomatology, abandon patients to avoidable suffering de
facto, which at the same time raises unavoidable ethical and
professional questions.
2 Outlines of Pain Physiology
The free Aδ and C fibre endings are at the origin of the
nociceptive message that reaches the central nervous sys-
tem (CNS) through a polysynaptic chain of which they
form the first link. These fibres, which are different for
morphology, conduction velocity and neurochemical char-
acteristics, also present specific biochemical receptors on
their membrane (such as purinoceptors, vanilloid and acidic
receptors) that form true elementary transducers to which
the polymodal character and functional plasticity of the
fibres themselves can be traced back. These receptors play
a fundamental role in the genesis of inflammatory pain as
well. Whenever, for example, tissue damage occurs, numer-
ous neuroactive substances such as chinines, cytochines,
prostanoids and peptides are released which when interact-
ing with these specific sites determine nerve fibre depolari-
sation or their sensitisation to algogenic stimulation. It is
useful to remember that prostanoids, and in particular
83
84
cyclooxygenase (the enzyme responsible for the synthesis),
represent the target of a class of drugs frequently used in
pain therapy – non-steroidal anti-inflammatory drugs
(NSAIDs) – which will be discussed later.
The primary Aδ and C afferent fibres reach the central ner-
vous system (CNS) through the posterior spinal roots where
they encounter spinal neurons: the specific nociceptive neu-
rons in the Rexed I lamina and the wide dynamic range
(WDR) neurons of the V lamina. The influences of the periph-
eral nociceptive stimulators (as well as non-nociceptive) and
inhibitors of both cutaneous and visceral origin, converge
upon the latter of these creating the so-called viscerosomatic
convergence at the basis of the projected pain phenomena
(e.g. the upper left limb pain reported in pectoris angina, or
the testicular pain reported in renal colic).
The release of a nociceptive impulse does not represent an
isolated phenomenon as it usually involves many adjacent
neuronal populations whose activation determines spatial
summation phenomena and therefore localised amplification
of pain.
While some of these neuronal populations rapidly exceed
the critical threshold required for depolarisation, silent neu-
ronal populations exist around them, in a subliminal state of
depolarisation that is insufficient to trigger an action poten-
tial. During inflammatory processes, such dormant neurons,
sensitised by the release of inflammatory mediators as previ-
ously mentioned, are recruited (even if spatially more distant
from the area subjected to nociceptive stimulation, such as
for example, the surface area of a cut), thus triggering phe-
nomena of hyperalgesia. Neuronal response is amplified by
sustained rapid trains of action potentials over time, facilitat-
ing depolarisation (wind-up), therefore associating temporal
summation to spatial summation phenomena.
The nociceptive impulse is then transported by bundles of
nociceptive neurons towards specific encephalic regions in the
reticular formation (gigantocellular nucleus, lateral reticular
nucleus) through the spinoreticular tract, towards the medial
and lateral thalamus through the spinothalamic tract, towards
the parabrachial area and the periaqueductal grey through the
spinoponto-mesencephalic tract. Furthermore, we must not
forget the projections toward the solitary tract nucleus, the
stimulation of which might be responsible for the neuro-vege-
tative manifestations mentioned above in the introduction.
From these integration and modulation centres the nociceptive
message is then transmitted to the cortical areas.
The processing of nociceptive messages should not be
considered a mere chain of excitatory synapses, as it is the
result of a subtle balance between excitation and inhibition
between different neuronal populations present at each level
of the CNS. Hence originating from the brainstem descend-
ing the inhibitory pathways can modulate the checks already
present at the spinal level itself. The opioid and noradrener-
gic systems interpret this role thanks to the specific receptors
G. Finco et al.
in pre- and post-synaptic positions able to hyperpolarise the
nervous membrane. Significant alterations of this balance
would seem responsible for the perception of pains triggered
by painful stimuli, a phenomenon known as allodynia.
Neurobiology of the synapsis involved in nociceptive
message transmission is complex and subject to precise
modulation mechanisms. Numerous neuromediators are
involved – the excitatory amino-acids glutamate and aspartic
acid, neuropeptides (P substance, somatostatins, cholecys-
tokinin), GABA, serotonin, norepinephrine – which involve
just as many specific receptor and transduction systems often
interacting between themselves (cross talk). A particular role
is without doubt played by NMDA and AMPA kainate recep-
tors, activated by glutamate and able to promote the release
of the glutamate from presynaptic membranes, in a positive
feedback responsible for sensitisation phenomena and “spinal
memory” (possibly similar to what happens at a hippocampus
level following long-term potentiation or LTP phenomenon).
Cox-3 involvement in such a transduction chain (consti-
tutive at a medullary level) offers an advantageous use of
paracetamol, which by inhibiting cyclooxygenase is able to
interfere in the maintenance of this “vicious circle”.
3 Elements of Pain Therapy
Acute post-operative pain therapy protocols should be pro-
vided in every hospital. A few essential factors must be taken
into consideration in post-operative pain management pro-
gramming, e.g. the surgical operation and patient characteris-
tics (Table 1). However, present knowledge does not allow us
to accurately predict the intensity of the pain that will require
treatment and above all the consumption of analgesics.
With this in mind, suitable pain measurement tables should
be adopted for a correct evaluation of therapy efficacy. Recent
recommendations of many scientific anaesthesia societies
regarding post-operative pain evaluation even propose that the
measurement of pain become one of the so-called vital param-
eters, like cardiac frequency, arterial pressure, body tempera-
ture and excretion, which should be monitored regularly over
the 24-h period with opportune evaluation tables.
Table 1 Determining factors of post-operative pain manifestation
Operation
Operation site
Intra-operational trauma characteristics and type of pre-
medication, preparation
Post-operative condition: drains, probes, etc.
Patients
Age, gender, individual pain threshold level
Social-cultural factors, religious beliefs, personality, anxiety,
depression, previous experiences
Drug dependence, overdose, side effects of drugs
Post-operative Pain Therapy
The visual analogue scale (VAS), presently considered
by most authors to be the scale of reference, represents a
rapid method of pain measurement and is easily used by
health workers and easily understood by patients. The
numerical scales however would appear more suited to
elderly patients.
Verbal scales are considered unreliable because the
adjectives used to describe pain intensity can be subjective.
In all cases training of the personnel involved is always
necessary.
Post-operative pain management should not be consid-
ered a separate intervention. It should be included in a wider
pre- and post-operative therapeutic context of the illness as
well as multimodal analgesia, early mobilization and enteral
nutrition and physiotherapy.
Post-operative pain can be managed through four dif-
ferent approaches. The first foresees the use of drugs that
target peripheral or central areas, such as opioids or
NSAIDs that are administered systemically (orally or
intravenously) – the former act by modulating pain inte-
gration in the CNS, whereas the latter limit the production
of algogenic agents (prostaglandin). This approach repre-
sents a simple method to apply because obviously it does
not require the use of any particular tool and is economic;
however, when opioids are used the disadvantages and
risks of these drugs can arise (sedation, respiratory depres-
sion, nausea and vomit, constipation). Careful patient
monitoring is required.
The second approach envisages the neuro-axial block
through the administration of local anaesthetics and/or opi-
oids in the peridural or subarachnoid space, which deter-
mines the blockage or altered transmission of pain impulses
at a spinal level.
Of all the methods available, this guarantees better con-
trol of analgesics but is more costly with regard to instru-
ments and higher training needs of the personnel responsible
for its implementation management.
The greatest disadvantages are the sympathetic blockage
determining hypotension and urinary retention and, to a
lesser degree, respiratory depression when opioids are
employed.
The third approach consists in blocking the nervous plex-
uses (brachial plexus, lumbar plexus, etc.) or the peripheral
nerves (radial nerve, femoral nerve, etc.) through the use of
local anaesthetics. This procedure is particularly efficient,
safe and easy to implement with the evolution of anaesthesia
techniques and of available materials, but it can be associated
with neuropathological risk when the catheters used to
administer the local anaesthetics remain in place over pro-
longed time periods.
The fourth approach entails the application of a local
anaesthetic in the incision site, which blocks the transmis-
sion of pain signals at a local level. This analgesic technique
85
is safe and relatively free of systemic side effects. The only
associated risk is represented by the toxicity due to exces-
sive dosage of the anaesthetic. In any case, administra-
tion of the drug must be carried out in an adequate manner
and must comply with the laws of pharmacokinetic and
pharmacodynamics.
The most frequently employed drugs in pain therapy are pri-
marily: non-opioid analgesics, opioid analgesics, local anaes-
thetics and adjuvants (ketamine, anti-epileptics, etc.). Among
the non-opioid analgesics we can include non-selective non-
steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygen-
ase 2 selective inhibitors (COX-2I) and paracetamol.
3.1 NSAIDs
These represent the most widely employed drugs in post-
operative pain therapy. Alone they are able to control slight
and moderate pain intensity. Randomised controlled trials
(RTCs) have also shown their advantageous use in multi-
modal analgesia (in which multiple drugs are used simulta-
neously in order to enhance the effects). This methodology
allows for reduced dosages of each drug to be used which
translates into a reduction of possible side effects.
In this regard, the association of NSAIDs with opioids
appears to significantly reduce the quantity of opioid
required, ensuring an improved pain level with respect to
levels obtained with any single drug.
Cyclooxygenase (COX) inhibition represents the basis of
the mechanisms in their efficacy and toxicity. It has been
demonstrated that COX is found in at least three isoenzymes:
COX-1, COX-2 and COX-3.
COX-1 is the form implicated in normal cellular activity
regulation, as occurs for example in the gastric mucosa, the
kidney and in platelets; COX-2 on the other hand is rapidly
induced to the inflammation site. Whereas traditional
NSAIDs are unable to discriminate the two isoenzymes,
COX-2 selective inhibitors manifest their anti-inflammatory
activity without altering the COX-1 homeostatic functions.
Therefore, the principal advantage of using COX-2 inhibi-
tors is found in the reduced risk of gastric bleeding and in the
absence of platelet activity inhibition. However, although it
is well known that NSAIDs lengthen coagulation times, and
the fact that in some studies an increase in blood loss has
been reported, data on the subject collected thus far often
offer discordant and incomparable results. In a study involv-
ing over 7,000 patients treated with ketorolac (a traditional
NSAID), the risk of post-operative bleeding was not seen to
be higher compared to the control group of over 7,000
patients treated with opioids.
Contrarily, a notable increase in the risk of post-operative
bleeding has been documented in patients on anti-thrombotic
therapy with non-fractioned or low molecular weight heparin
86
(LMWH) associated to NSAIDs. The COX-2I could repre-
sent a valid alternative to traditional NSAIDs, with which
side effects would not be shared. For example, in vitro stud-
ies have shown that parecoxib (a COX-2I) does not influence
platelet aggregation. With regard to gastro-intestinal and
renal side effects, further studies are required to obtain con-
clusive results. As with non-selective NSAIDs the use of
COX-2I must be adequately pondered in patients with a his-
tory of myocardial infarction, cardiac insufficiency, kidney
and hepatic insufficiency. Despite controversy regarding
possible cardiovascular side effects, at present selective
COX-2 inhibitors, such as parecoxib and celecoxib, are con-
sidered as efficient as non-selective NSAIDs and their use is
recommended in post-operative analgesia.
3.2 Ketamine
A meta-analysis in 2006 considered the use of ketamine in
post-operative pain therapy. It proved efficient in 54 % of
cases and showed positive outcomes in reducing the con-
sumption of morphine administered in association without
however significantly reducing the discomfort caused by its
side effects. Due to its peculiar mechanisms of activity, it
also proved effective in preventing the development of
hyperalgesia, of tolerance to opioids and above all the onset
of chronic post-operative pain.
3.3 Gabapentin
An analogue study in the same year reported disappointing
results regarding the analgesic efficiency of gabapentin – a
new-generation anti-epileptic – in acute pain management.
Gabapentin is an anti-epileptic routinely employed in chronic
neuropathic-type pain, and offers excellent analgesic results
in this kind of pain.
In recent years its use in surgery-derived pain has been
hypothesised, in the conviction that it can exercise a “preven-
tive” action on the post-operative pain. Its association with
opioids does not seem to offer improvement in post-operative
patient symptomatology whilst the incidence of sedation
results increased.
3.4 Paracetamol
Widely used in mono-therapies, it is efficient in the treatment
of mild to moderate pain and appears to possess antihyperal-
gesic properties (as mentioned in the previous paragraph of
this chapter). It has an elevated therapeutic index and side
effects are scarce. Its efficiency in the treatment of post-
operative pain in a number of operation types, and at
G. Finco et al.
commonly employed dosages, has been compared to that of
about 10 mg of morphine. Considering its slow kinetic activ-
ity it is preferable to plan its use (30–60 min prior to the
onset of pain), which should be repeated at regular 6-hourly
intervals. It can also be associated to other classes of analge-
sics in multimodal therapies (see below).
3.5 Opioids
Opioids still represent the current reference drug in the treat-
ment of moderate to severe pain. However, their side effects
render their management difficult and less safe compared to
the previously mentioned class of drugs.
Respiratory depression, nausea and vomiting or reduced
intestinal motility strongly limit its use.
Furthermore, we must take into consideration that hepatic
or renal insufficiency can significantly alter its metabolism,
and both patient age and marked individual sensitivity differ-
ences impose attentive personalised dosages.
Morphine remains the reference drug; its dosage can be
finely tuned based on analgesic requirement and administra-
tion repeated every 4–6 h. Subcutaneous and intravenous
delivery are the preferred methods of administration, the lat-
ter utilised in small fractioned doses (1–4 mg) repeated every
5–10 min until the desired effect is reached or through the
use of special electronic pumps capable of administrating
pre-established doses as requested by the patient at con-
trolled intervals (patient controlled analgesia or PCA), or
through continuous infusion.
New opioid substances such as oxycodone and hydromor-
phone have been introduced into clinical practice in recent
years and also new pharmacological formulations like trans-
dermal patches, slow-release tablets, individual disposable
PCA systems, which have increased the indications for use
of these drugs in acute and chronic pain. This is due to the
improved cost/benefit rapport offered by these new formula-
tions. For example, the use of slow-release tablets, which
allows for a single daily dose and are administered a few
hours prior to surgery, can guarantee good pain management
for about 20 post-operative hours to all surgical patients
without the incidence of the severe side effects caused by
opioids and without the added need for medical and nursing
personnel to administer and control the analgesic drugs.
3.6 Tramadol
This is another drug currently much employed and often rep-
resents a valid alternative to strong opioids. It consists of a
racemic mixture in which the levorotatory isomer targets the
serotoninergic and monoaminergic pathways, whereas the
M1 metabolite of the dextrorotatory isomer possesses affinity
Post-operative Pain Therapy
for the μ-receptor. Therefore it possesses a double action on
pain modulation at the spinal level. The analgesic effect of
100 mg of tramadol is comparable to that of 10 mg of mor-
phine. Side effects include mild sedation and less frequently
nausea and vomit (resistant to “setrons”) but not respiratory
depression.
3.7 Local Anaesthetics
As far as their use is concerned, it must be remembered that
by interacting with the ionic channels they are able to block
action potential in all conductive fibres; thus their activity,
should they be accidentally introduced into blood circulation
or higher than recommended doses employed, can manifest
itself at CNS or myocardial level with convulsions or arrhyth-
mia. The infusion of local anaesthetics directly in the wound
using multiperforated catheters represents a simple and
promising technique able to improve post-operative analge-
sia. A number of observations would appear to confirm the
capability of local anaesthetics to prevent the appearance of
sensitisation phenomena of central nervous system origin.
In breast surgery, for example, chronic post-operative scar
and thoracic wall pain is apparently quite common. Nervous
blocking in these areas not only relieves acute pain but also
contributes to control sensitisation phenomena. Prolonged
action anaesthetics, such as levobupivacaine (0.125 or
0.25 %) and ropivacaine (0.2 %), are preferred when choos-
ing which one to be employed – as they are able to induce a
sensitivity block – and the one possessing a higher therapeu-
tic index compared to older generation anaesthetics.
4 Multimodal and Preventive Analgesia
As nociception is a complex phenomenon, regulated by mul-
tiple mechanisms and at various CNS sites, it would be rea-
sonable to adapt therapeutic strategy in order to obtain
synergic or additive effects between different classes of
drugs or with different modes of activity. This principle con-
stitutes the conceptual basis of multimodal analgesia. The
desired objective is evident: improve the quality of the anal-
gesia by reducing the doses of each drug and if possible their
side effects.
The association of NSAIDs and opioids is the most fre-
quently used combination although a number of variations
are of interest and are currently undergoing clinical verifica-
tion. An interesting study carried out in 2005 demonstrated
how orally administered paracetamol and tramadol is suffi-
cient to guarantee adequate analgesic cover following lipo-
suction. The association of paracetamol-oxycodone (a
semi-synthetic opioid) has also obtained promising results in
a number of studies. Other tri-therapy models in which
87
paracetamol is associated with NSAIDs or opioids have also
been proposed.
A recent study demonstrated the advantageous use of
gabapentin, administered prior to surgery, in combination
with a COX-2 selective inhibitor.
In this manner, the association of an antihyperalgesic with
an analgesic has been validated. The use of such drug asso-
ciations, as well as of the NMDA antagonists (ketamine),
represents a useful therapeutic strategy, even if it is yet to be
definitively confirmed.
Pre-operative administration moreover, prior to pain stim-
ulation, aims to interrupt both peripheral and central sensiti-
sation phenomena even before they are activated; this
strategy constitutes the rationale behind the so-called pre-
emptive analgesia. Every class of drug is commonly
employed to this end: from common NSAIDs to opioids,
from gabapentin to ketamine. The latter, in particular, finds a
specific use in virtue of its presumed ability to inhibit neuro-
nal wind-up.
However, despite encouraging premise in animal-model
experiments, clinical observations have often provided con-
trasting and inconclusive results. From the review of interna-
tional literature, in which the results of 80 randomised and
controlled studies were compared, no pre-emptive therapy
compared to post-operative ones resulted more effective.
It has been observed that neuronal sensitisation processes
are in reality initiated by prolonged exposure to pain stimula-
tion. The timing with which analgesic therapy should be
started would therefore be less relevant compared to therapy
duration, which should cover the entire period of application
of the stimulation. This different therapeutic approach has
been defined as preventive analgesia; it also implicates and
integrates multimodal analgesia.
Even if general consensus exists regarding the benefits
that derive from the rational application of these strategies,
new studies are required to evaluate which methods and
drugs are the most appropriate in order to inhibit the devel-
opment of hyperalgesia, reduce post-operative pain duration
or prevent its becoming chronic.
Acknowledgement We thank Mr Barry Mark Wheaton for his invalu-
able linguistic assistance with this work.
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 The American Legal System
Neal R. Reisman, Gerald F. Kaplan,
and Steven M. Gonzalez
1 Introduction to the Law
The American legal system and the “Rule of Law” attain a
leading place in the world yet generate much criticism. It
clearly evolved from common law with specific European legal
influences. Its critics state it is too much in favor of the person
bringing a lawsuit, often criticizing plaintiff attorneys and
deeming the lawsuits frivolous. Angry patients have murdered
physicians, making the threat of a lawsuit far less threatening
than the threat of bodily injury and harm. A key in understand-
ing our legal system is the word “foreseeable”. If your behavior
or a result is “foreseeable”, there may be legal consequences
for your failure to address and prevent this issue.
This chapter will address the complex nature of the
American legal system as it pertains to healthcare and spe-
cifically plastic surgery. It would be beyond the scope of this
chapter to reach a level of understanding for a law student, so
I will restrict the discussion to the practicing plastic surgeon.
The aspects of discussion will include torts, the law of negli-
gence, as well as other areas affecting plastic surgery includ-
ing warranty issues, privacy issues, fraud, product liability,
and the FDA, which covers the use of drugs and products
including injectables and implants. In addition, parts of this
chapter reflect a plaintiff’s attorney and a defense attorney’s
viewpoint.
One might wonder why there is even an interest in this
topic. Many physicians follow Shakespeare’s comments in
King Henry VI, Part Two, Act 4, Scene 2, in which the com-
ment is made “The first thing we do is let’s kill all the law-
yers.” The fact, however, is that the legal system controls
N.R. Reisman, MD, JD, FACS (*)
Chief of Plastic Surgery, Baylor-St. Luke’s Episcopal Hospital,
Houston, TX, USA
e-mail: drreisman@hotmail.com
G.F. Kaplan, MD, JD
Attorney at Law, Philadelphia, PA, USA
S.M. Gonzalez, JD
Steven M Gonzalez & Associates PC, Attorneys at Law,
McAllen, TX, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_9
much of how we practice, as in Worker’s Compensation,
much of the contracts associated with Managed Care, as well
as our everyday employee interactions and other practice
issues. We cannot live without attorneys. Furthermore,
despite the concern, anguish, and often, resentment of cer-
tain aspects of the legal profession, we look and strive for a
good relationship with our own personal lawyers. This edi-
tion is not an attempt to establish a standard of care by which
physicians should practice. The goal is to explore how our
legal system affects the practice of plastic surgery. There are
frequent causes of liability, usually revolving around the bal-
ance between risk taking and desired profit. Areas of this
discussion will focus on areas of the law where the desired
goal improves the practice, but often at some expense, not
only monetary, but add liability.
What is the perception of the physician? Often the atti-
tudes of society in viewing physicians as “Marcus Welby”
or “Dr. Kildare” of the past or the newer generations may
have more understanding of George Clooney in his role in
“E R”, the caring and wonderful complete physician. The
opposite perception is the greedy physician, who will cut
corners to make a profit and who utilizes nonmedical staff
to perform medical functions. This perceived greedy physi-
cian would have the staff treat patients, often without the
physician being there to either direct or supervise, and is
too busy becoming efficient and therefore cannot provide
adequate care.
There are multiple areas of the law. The high-risk areas
clearly involve malpractice, TORT law or negligence.
However, additional areas of risk are created by other areas
within the law that would apply to a Plastic Surgery practice.
These include breeches of warranty, if established. Product
liability, ever increasing with the sale of skin care and other
products through the office is another. Fraud and abuse is
always a potential in billing and representations to patients.
Managed care has its own entire level of risk. An aesthetic
practice may have patient selection issues and its own areas of
risks. The employee-employer relationship, deemed agents of
law clearly affects the plastic surgical practice as well as part-
nerships, associations, and office sharing events. HIPAA, The
89
90
Health Insurance Portability and Accountability Act of 1996,
adds another layer to privacy concerns as to disclosure about
a patient’s care and treatment, to whom and with what written
approval. Informed consent is always important when dealing
with medical/legal risks.
2 Malpractice
There are four elements required to succeed in a TORT or
medical malpractice case. The plaintiff’s attorney, whom
you will hear from later, must establish four elements to
achieve a successful claim in negligence. The first is a duty
of care. That duty must result in a breech of duty, which is
the hallmark of a malpractice claim. Furthermore, the breech
of that duty must be the proximate cause of damages that
must be a component. So therefore, the four elements are: (1)
a duty of care to render some level of treatment; (2) a breech
of that duty; (3) a proximate cause, the “but-for” theory, in
which the breech specifically results in damages which is the
fourth element. The duty of care is difficult to escape.
Clearly, there are many established standards of care, but the
duty is often one that is present in today’s practice. In the
managed care environment, the duty is established with a
contractual relationship with the managed care entity. One
must always be concerned about seeking an exclusive
arrangement because if that is established, then the physician
must provide care at all hours and times as designated in the
contract. If the physician is on call in the emergency room,
whether he or she sees or hears of the patient seen in the
emergency room, the physician has a duty to evaluate and
render care for that patient.
There are other issues arising from a noncontractual
patient evaluation. If it is not life threatening as determined
by the patient, there may not be a duty of care established
and the physician should be very clear about whether he or
she accepts the patient. If the physician does not accept the
patient, then they should warn the patient about the conse-
quences of no treatment and refer them toward physicians or
other sources of care such as county medical societies.
Staff comments can create a duty of care. For example, if
the physician is in the operating room, and a patient comes to
the office with a specific complaint, and the office staff or
nurse recommends some form of treatment or care, i.e., “pro-
vide more compresses,” or “keep it elevated”. Such a recom-
mendation creates a treatment or care in which the patient
relies, and therefore a duty of care is established. In fact, a
lawsuit can be brought against a physician even though the
physician has never seen or heard of the patient. If the physi-
cian is visiting one of his or her patients in a four-bed room
and notices another patient in some level of distress, there is
not a specific duty under the law to render aid unless the
physician produced or caused the stress that this other indi-
N.R. Reisman et al.
vidual is experiencing. If the physician is walking down a
street and notices someone injured, there may be an ethical
and moral duty to intercede and render aid, but there is not a
legal duty to do such unless the physician produced or caused
the injury of question. The interaction of law and medicine is
difficult due to a presumption in the law, through case law,
that makes it likely a physician will render negligent care.
An oversimplified fiction would be a person, Bob, walking
down the street smoking a cigarette. Bob sees a child riding
on a bicycle toward him, and Bob’s past anxiety, anguish,
and stress relating to a “Dennis the Menace” type neighbor,
pops into Bob’s head. Bob impulsively and devilishly tosses
his cigarette butt in the direction of the child, resulting in a
blaze of an oil slick and the child receives a burn. Clearly,
Bob is directly responsible for that injury and all of the sub-
sequent things that may happen. The ambulance taking the
child to the hospital is involved in an automobile collision in
which the child breaks his leg. Bob is now also responsible
for the broken leg because it is foreseeable that rescuers may
be injured, and the initial act that results in an injury bringing
the rescuer assumes the liability of rescuer as well. So now,
Bob is directly responsible for producing the burns in the
child, and the broken leg. The fictitious saga continues and
an orthopedic surgeon negligently sets the fracture of this
child and there is a malunion established. Bob is also now
responsible for the negligence of the orthopedist, along with
the orthopedist, because it is foreseeable that hospitals and
physicians will be negligent. Therefore, once the injury
occurs, any rescuer’s further injury, or medical care’s further
injury becomes the fault of the initial person who produced
the accident in the first place. In the last bizarre example,
imagine that a tornado destroyed part of the floor of the hos-
pital, and the burned, broken-legged child receives additional
injuries because of this event. Acts of God and non-
foreseeable acts of others are not attributed to the initial per-
son causing that injury, Bob. This bizarre set of circumstances
should help one to understand that an act of substandard care
will depend a lot on expert testimony. In every malpractice,
case there is a battle of experts – the experts for the plaintiff
versus the experts for the defendant physician. The deviation
from the substandard care must directly produce damages
and, as a result, the four elements of the malpractice cases
are established.
Proximate cause, one of the required elements of a negli-
gence action, can be misunderstood as an element in a mal-
practice case. Assume with me that a man received an injury
lacerating a digital nerve with glass breakage on his left non-
dominant hand ring finger. He visits an emergency room, no
x-ray obtained, and an examination initially fails to diagnose
the digital nerve injury. Assume with me that it would have
been negligent not to get an x-ray looking for particulate
leaded glass. In addition, it is negligent to miss the digital
nerve laceration. The lack of an x-ray has no relationship to
The American Legal System
missing the digital nerve laceration and, therefore, even
though there is a substandard act of failing to order and eval-
uate an x-ray, it does not result in damages due to missed
diagnosis of the digital nerve injury. Therefore, the failure of
obtaining an x-ray would not be a necessary element in pro-
ducing this TORT claim. Physicians often question the dam-
age element. There are tangible and intangible damages,
which are very broad. The defendant physician commonly
believes there are no damages. However, the creative plain-
tiff’s attorney will be able to describe damages the plaintiff
patient experienced.
Malpractice and TORT law consumes the majority of legal
issues in the plastic surgery practice. However, more and
more additional claims of fraud, product liability, warranty,
and privacy issues are seen. Why would a plaintiff’s attorney
begin to include these other components? The answer often is
the “Stowers Doctrine.” The Stowers Doctrine states that if
the defendant physician demands that the liability insurance
carrier company settles a claim up to the dollar limit of the
physician’s policy, and the carrier fails to do so, if there is a
judgment in excess of policy limits, the insurance company is
responsible for that excess. Therefore, many plaintiffs’ attor-
neys will put pressure on the defendant physician by adding
complaints and claims that are not covered by liability insur-
ance such as fraud, product liability, breach of warranty, and
often privacy issues. This sets the stage for much of what
occurs with interactions with attorneys.
The malpractice arena has continued to grow, altered
somewhat in states with TORT reform, but not eliminated.
Unfortunately, malpractice occurs, and the difficulty is, once
a claim is filed, the entire record and actions evaluated retro-
spectively under a magnifying glass. Patients rarely bring a
lawsuit against physicians they consider caring and friendly
to the patient and family. It is my desire that attitudes in plas-
tic surgery practices evolve as a team approach with all
employees and physicians in the practice addressing patient
needs and care as well as appropriate representation of risks
and benefits with each procedure. I truly believe that the
plastic surgery practice will be very successful if patients are
cared for in this fashion rather than specific acts that will
generate either more patients or more business while avoid-
ing simply providing excellent patient care.
3 Plastic Surgery Office Risks
We have already discussed what binds the practice to patient
care, that is, ER call, managed care contracts, and staff com-
ments. An important aspect of office risk is recognizing dif-
ficult patients and recognizing patients that are so disruptive
and continue not following physician advice to pose great
risk to them. These patients need to be fired from the plastic
surgical practice. There are many ways to achieve this; how-
91
ever, I believe there are some necessary guidelines. First,
everything written in a business environment becomes a
business record. So the words chosen in a letter to send to the
patient when firing them should be written with great care,
not accusatory, not demeaning, and not inflammatory to the
patient. It seems appropriate to use language as “I can no
longer be responsible for your care and outcome because of
the many times you’ve failed to follow specific instructions.”
There is a mail presumption that says when a letter is mailed
it is received. This is rebuttable in that the patient may claim
that they have never received this letter because they have
never received their mail. There may be some problems with
this, and therefore sending the letter as both certified and
regular mail is advisable. One must give appropriate time for
the patient to seek other care providers and/or sources of care
providers. I would notify your entire office, emergency
room, and managed care company, if this action is taken,
because the physician may be on call when this person comes
back to the emergency room and now there is an issue as to
who comes in to provide care when they are not on call. The
exclusive contract with the managed care company, which
should cover refusing to care for this specific patient, must
also receive notice.
The personnel in a plastic surgical office add specific ethi-
cal and legal risks as well. Acceptable hiring practices,
restricting discussions about family and personal traits are
important. I strongly suggest a Policy Manual for employees
updated periodically, providing good instructions as to what
behavior and actions are required and prohibited. One should
be very concerned and cognizant today of sexual harassment
as both an ethical and legal issue in the plastic surgical prac-
tice. The intent of the speaker of such language is not the
proof of a sexual or offensive connotation. Harassment,
solely determined by the listener, defines offensive language
or actions. Anyone under the physician’s control or supervi-
sion is subject to a claim of harassment. In addition, one
should be very aware of jokes that are told in a business set-
ting, of religious and personal comments that one individual
may find offensive and not another. The listener, feeling
offended, can file a lawsuit that is not protected or covered
by liability insurance. This can be a major concern to the
Practice, often with results announced in public papers for
the world to see.
Additional ethical and legal issues concern confidential-
ity. The Policy Manual should be very explicit about not dis-
cussing patient issues with anyone outside of the Practice,
and following HIPAA’s rules as to who can receive informa-
tion about a patient.
It is wise to have employees that handle cash bonded so if
there is a theft, embezzlement, or loss, the Practice is cov-
ered. Other office issues concerning OSHA (Occupational
Safety and Health Administration), and the regulatory
administrative requirements should be read and adhered to.
92
Agency Law states that the employer is responsible for
“acts of the employee in the scope of employment or in fur-
thering the employer or business.” This takes on an added
meaning if there are, for example, seminars on a weekend
and there are negligent claims arising out of employee par-
ticipation. Even though it may not be in the scope of employ-
ment in the regular course of a plastic surgical practice, it is
in furtherance of the employer and therefore, most likely
covered under Agency Law. The practitioner should be
aware and have some level of supervision because even
though they may have no knowledge of illegal, unethical or
negligent acts of an employee, it is possible they should have
known if a prudent employer/physician were functioning in
a supervising role and this would have been evident. It is
important, I believe, to include in a Policy Manual what the
employees can and cannot do. A non-M.D. cannot practice
medicine, so language prohibiting refilling medications
without M.D. knowledge, prescribing medications without
M.D. knowledge, accepting a patient without M.D. direct
knowledge. Other issues, such as smoking, vacation, tele-
phone, number of personal calls, information released,
agreeing to the confidentiality and proprietary information
associated with the Practice are covered.
A common complaint arises when an aesthetician leaves a
practice and believes that all of the physician’s patients
belong to the aesthetician and not the plastic surgeon. All of
a sudden, the patients are receiving information from another
practice, which is both confusing to them and often irritating
to them, in addition to lost revenue to the practice. Therefore,
the Policy Manual should include who controls and owns the
information about each patient. The employee cannot take,
use, or transmit that information to any other person without
direct, written approval by the Practice as well as the patient,
complying with HIPAA and privacy requirements.
I think it important also to include financial components
that, “from time to time, as an executive decision of the phy-
sician, fees may be waived and balances may be written off.”
I think that this becomes important should there be funds
returned to patients and not have it perceived as an admission
of negligence, but actually included and covered in the Policy
Manual. All employees should sign and date the Manual,
updating it periodically, as to grievances, privacy issues, and
normal employee contractual issues, remembering to keep
old manuals. The more requirements defined avoiding mis-
understandings, the less employee liability in the Agency
world from acts of the employee that bind the Practice.
“Fraud” is “the intent to deceive.” “Abuse” is “the intent
to confuse.” There are a number of elements of fraud and
abuse that may be a part of the plastic surgical practice.
There is no liability coverage for fraudulent activity. The
finding of fraud in a malpractice case makes the entire case
that much more difficult to win and defend. Moreover, there
are critical areas in billing, correspondence, and third-party
N.R. Reisman et al.
communication that expose the Practice to fraudulent con-
cerns. Altering records should never occur. There are meth-
ods of correcting a record, which is to contemporaneously
within the proper area of the record make a note that a mis-
statement had occurred on the date above and corrected. Sign
and date it. Through the misstatement put a single line so the
entire wording is readable; sign and date that. This avoids the
whiteout, the blackened sentence that in the future, in a
courtroom, will be whatever the plaintiff’s attorney deems it
to be. In addition, in many states, altering a medical record
has criminal exposure and liability, and often may result in a
felony and, if convicted, loss of license.
A fraudulent act tolls the statute of limitations. In other
words, it delays the statute of limitation and, therefore, a
claim may continue even though the statutory period for the
claim has ended. Another component of fraud is “fraudulent
concealment,” and this, in fact, follows all of the previously
stated fraud components. However, here, if a statement is
made, knowing or should have known that it is false, to a
patient and the patient relies on that statement to their detri-
ment, then that may create a fraudulent concealment condi-
tion. A simple comment such as “Don’t worry, You’ll be
OK” to a patient when the physician knew that they may not
be OK and in fact may have serious consequences that were
not relayed to the patient, has been enough in case law to
fulfill a fraudulent concealment claim.
The misrepresentation of facts necessary for the patient to
make decisions is another element of fraud. There are certain
aspects of care that, if misrepresented to the patient, and the
patient relies on that statement to their detriment, not only
may they bring a claim in negligence and malpractice, but
the added pressure of the lawsuit is enhanced with a claim of
misrepresentation or fraud.
Billing is a classic act where fraudulent components and
issues may be suspect. The Practice should be very careful
to review billing CPT codes sent to third parties and confirm
that operative reports accurately reflect the codes submitted.
It is common, however, for the managed care entity to change
the codes, sometimes to a lower reimbursable level. Then the
Practice readjusts the codes and submits them again, leaving
a suspicion of billing discrepancies. There should be com-
plete agreement between operative records, office notes, and
bills submitted. Clearly, the Practice should not bill for ser-
vices not performed. There should not be upcoding. There
should not be any misrepresentation to obtain coverage, and
failing to do so may further expose the Practice to liabilities.
Qui-Tam is a component of the false claims act – USC
3729–3733, which creates law that an employee can file a
lawsuit against you, the practitioner, for fraud. In addition,
the United States Government joins the suit. The employee
gets to recover a reward, a percentage of settlement or judg-
ment for reporting you. The lesson here is to assure that bill-
ing is exactly representative of prior documentation and did
The American Legal System
occur in treatment, and that the record must support the con-
tinued alteration of the CPT codes, often necessary with
managed care billing. If there is a hostile employee, angry
toward the Practice, there should be suspicion and caution
about having them remain at work, especially if the Practice
has federal claims, Medicare and Medicaid, and government
issued insurance programs, all of which may be a basis for
such a Qui-Tam lawsuit.
Lastly, although this is not as frequent in plastic surgery
practices as in other areas of medical practice, the Justice
Department has a Fraud Task Force, and will continue to
evaluate codes that are placed as comprehensive and longer
in care than actually performed, demonstrating fraud. The
newest concerns are programs involving drug and device
companies in which the Practice and practitioner receive
financial rewards for patients being included in the study.
There may be a concern that appropriate patient care and
patient decision choices are made and that a perceived uneth-
ical slant toward increasing remuneration and inclusion into
the study overshadows patient care and quality issues.
Buying or paying for referrals is always illegal.
4 Aesthetic Plastic Surgery Liability
Today’s cosmetic plastic surgery practice poses added risks to
the plastic surgeon and office staff. From patient selection
choices to the increase in competition from within and out-
side plastic surgery, the level of medical/legal liability and
risk increases. Overhead in the plastic surgical practices con-
tinue to increase; competition similarly increases from in and
out the specialty; there are demands from family for your
time, and one of the suggestion is for the plastic surgical
office to become more efficient, to have staff be cross-trained
in all different aspects of care as well as selling products and
services. There is pressure to increase conversion rates from
consultation to surgery, along with internal/external market-
ing, finance programs, Internet exposure and referrals, all
placing added demands on the Practice to remain safe. The
busy practitioner is often too busy to spend time with patients
and has the staff perform a number of acts, including all of the
informed consent, laser skin treatments, laser hair treatments,
and filler injections, as well as Botulinum Toxin treatments
for facial rejuvenation. Many of the patient discussions and
demands can become financially driven with large overheads
and marketing programs that are excessively expensive.
Financing packages through Internet promises cannot only be
expensive but leave the perception of paying for referrals. The
liability issues continue with poor patient selection, false and
misrepresented advertising to bring the patients in; added
product liability on any product that is given, sold, or distrib-
uted from the Practice. Warranty issues when one promises a
certain result or the patient’s expectations are of a certain
93
level, time, and recovery, and the Practice does nothing to
dispel those expectations and reliance. Lastly, contractual
issues with independent contractors that may include office
anesthesia, office operating room nurses, aestheticians, and
similar other support staff.
5 Managed Care Risks
There are a number of reasons why managed care exposes
the plastic surgical practice. There are a number of concerns
including contracting issues, data issues about procedures
being performed, accounting issues, authorization and refer-
ral issues, appeal issues, and renewal issues. The major con-
cerns involving managed care involve the contract itself and
“hold-harmless” clauses as well as the appeals process and
utilization review. All of these combined demand a critical
overview of the managed care contract, its impact on the
Practice, and the necessary evaluation of data, reimburse-
ments and contract issues to maintain some level of protec-
tion for the Practice. Let us look at the appeals process first.
Case law demonstrates that when one has received the denial
for services and care, which the physician feels is medically
necessary, it is the responsibility of the physician to notify
the managed care entity, in writing, of why the care will be
interrupted and why the requested tests or treatment is medi-
cally necessary. Merely calling the managed care director or
putting responsibility on another does not alleviate the physi-
cian’s duty and responsibility to providing care. And it has
become critical to look at contract language about how the
utilization review process occurs and, in fact, who is a par-
ticipant in the care and does this expose the practitioner to
added risk.
When there is a denial for requested treatment and/or
diagnosis/diagnostic tests, the first step would be to discuss
this with the patient member of the program to try and get
them to initiate a response from their work relationship with
the managed care entity. Second, in writing, send a letter
either certified or with a good tracking system for when this
was sent to the managed care company. If you hear nothing,
it is wise to then call and document to whom you have spo-
ken, date and time, and response. There is liability relating to
damages and a negative outcome to the patient for failure to
obtain either treatment or appropriate diagnostic tests.
Moreover, when the managed care company fails to cover or
authorize this, the responsibility lies with the physician.
The contract itself needs careful evaluation. Utilizing
state medical societies and often their sections for review and
evaluation can help the physician practitioner in this regard.
The clear language to be concerned about is the “hold-harm-
less” clause. If the company fails to achieve a standard of
care necessary for the treatment or care of the patient,
that you then hold the managed care entity harmless for such
94
negligence and therefore assume all of the responsibility and
liability for the negative outcome. The language has changed
over the years, and in fact, it is not “hold-harmless” any
more. The current language in a contract now is similar to all
aspects of utilization review are to be “hold-harmless” and
no blame will be attributed at the managed care entity level
for utilization decisions.
It may be suggested to cross this out and replace this with
“each entity shall be responsible both for its own liability”,
so if the managed care entity is negligent in terms of what it
authorizes, they are responsible as long as you have placed
them on notice with certified written comment. Evaluate the
contract as to terms and renewals. Can you terminate without
cause? Can they terminate you without cause? There is often
an issue where the physician is terminated without cause and
therefore no longer able to participate. As upset as the physi-
cian is, that still is desirable when looking at no option for
the physician to terminate without cause. If the entity
becomes bankrupt and unable to meet its fiscal requirements,
unless you have a clause that says that you can terminate the
relationship, you may still be responsible for providing care
to all of the members without any hope of reimbursement.
Look at the renewal dates in advance; develop some form of
“tickler” file, so you reminded yourself approximately a
month before the contract ends, allowing evaluation of their
reimbursement, their utilization, and other policies to see
whether you even desire to renew.
Your managed care fee structure is becoming more and
more tied to Medicare fees. If your level of reimbursement is
below Medicare, the Practice is now on notice that having one
contract that is lower demands that the other contracts you hold
may also require a lowering to match the lowest reimbursement
profile, based on the percentage of Medicare. Physicians are
always looking to place themselves at even positioning with the
managed care institutes. However, managed care antitrust con-
cerns are always ever looming. There are two components to
the antitrust concerns with managed care.
The first is the anticompetitive component; namely, how
many physicians that perform the same CPT code in ques-
tion are in your geographic area. If the number for a nonex-
clusive contract is above 30%, it may reach anticompetitive
levels in which the managed care company will complain to
the Justice Department and there may be an investigation.
Nonexclusive members should be less than 20% of all treat-
ing physicians in the geographic area who may perform a
certain CPT code. Often this is not only plastic surgeons, but
given the overlap between specialties, one must look into all
physicians who perform the procedure, and count the num-
bers quite specifically. This becomes a significant issue when
looking at the ability to protect oneself.
The second component involves a conspiracy; that is,
conspiring to set fees, which prohibits a competitive free
market. This becomes critical when you are discussing fees
N.R. Reisman et al.
and therefore should only discuss fees with partners, true
partners, and those physicians in practices with whom you
are clinically integrated; that is, either share risk, have one
tax number, and are able to meet the Justice Department’s
requirements for clinical integration. Merely sharing an
office, a member of a hospital staff, one of the many physi-
cians on a managed care panel is not a suitable reason to
discuss your surgical and reimbursement fees. Those who
are participants in IPAs (Independent Practice Associations)
and larger hospital networks must use the messenger model,
by which the IPA contract is accepted. This is necessary to
avoid a conspiracy, antitrust violation by having all the par-
ticipants discuss fees openly. The messenger model requires
strict adherence, and this is often difficult. Moreover, the
physician’s temptation to complain about low reimburse-
ments and therefore discuss fees is a problem. A necessary
review of the contract for “hold-harmless” clauses, terms of
the contract and termination options, should also include the
required time of your bill submission, and when can the
company reject the payment due to late submission. It is also
important to know how long before payment, once services
are provided. Look at who the referring physicians are,
whether there is appropriate pathology, operating facilities,
diagnostic facilities, and tertiary specialists. Otherwise, it
may be difficult to provide a level of care that you deem nec-
essary, when the panel does not include appropriate physi-
cians to fill in the network completeness.
A common occurrence is that a patient receives emer-
gency care by you and after the care is provided, the follow-
ing day the patient calls your office and says that they can no
longer see you; the managed care company is directing them
to another practice across town. The best recommendation is
to tell the patient that you need to follow up and check your
progress. You will not be sending a bill for this, but it is nec-
essary to document the patient’s progress. You will receive
no reimbursement for this care or service. This becomes
important because if you fail to see a patient after you have
provided care, you have no way to document successful
completion of your treatment and an appropriate status of the
patient before they seek care elsewhere. So even though you
will not be reimbursed, and it is a direction that the patient
may block at some point, be as forceful as you can and nice
as you can, as compliant as you can to at least be able to
document resolution of the initial problem in your medical
records before the patient is sent elsewhere.
Evaluate the managed care contract to make sure that the
company cannot unilaterally change the contract in mid-
stream without your ability to dispute this and/or terminate
your relationship. The legalese of these contracts often
makes it difficult for the nonlawyer to evaluate and therefore
it is wise to seek city, county, or state medical society assis-
tance or even your own attorney to evaluate levels of contract
language.
The American Legal System
When you submit an authorization request, you really
must be quite honest in your description. This is a business
record. It will be admissible in court and you do not want to
approach a perception of fraud by clearly over describing
and dishonestly presenting the patient’s history and symp-
toms. There are patients who have no other source of insur-
ance other than either work related and if the injury or
medical treatment is not a direct result of the work; therefore,
they have no active insurance. Avoid the temptation to create
a work-related injury to achieve coverage. This usually
comes back to haunt the practitioner and becomes a question
of fraudulent behavior, which can severely affect a malprac-
tice case to the point of having it nondefensible.
6 The Plaintiff Attorney Viewpoint
Gerald F. Kaplan, MD, JD
Maybe you just received the latest bill for next year’s mal-
practice coverage; maybe your deposition in that abdomino-
plasty case is scheduled for next week; or maybe last week
your secretary handed you the latest complaint your office
was served with – your third suit in 5 years – and each of
them, nonsense, without an ounce of substance. If this keeps
up, what will my premiums be next year? Will I even be able
to get insurance? How do I fight this?
In life, “stuff” happens and sometimes, understanding the
nature of the “stuff” is the booby prize that gets you no closer
to a solution. But at other times, a measure of insight into the
stuff’s nature turns out to be a productive place to start. What
follows is some stuff.
6.1 Who We May Be – Introductory
Considerations
Most doctors are of the opinion that we are a group of strik-
ingly heterogeneous individuals. Orthopedists rarely if ever
sit down to lunch with pathologists and few plastic surgeons
ever go clothes shopping or golfing with pediatricians. And
even within each specialty there are widely divergent points
of view. But on the other hand, in accordance with academic
demands and the selection process, physicians have an unde-
niable degree of homogeneity. Though elements of art often
define what we do and permeate our craft, our immersion in
the “concrete” basic sciences during our formative years
shapes our collective core And it is that same concrete ground
of being that pervades our personalities when we emerge
from academia and enter the “real world” – academically
gifted though novices at life, at age 30 or so. While concrete
reasoning serves us well throughout our training, life outside
often turns out quite different when certain realities intrude.
95
For example, envision an instance where out of nowhere,
someone with no real understanding of what we do profession-
ally challenges THE DOCTOR—ME. The first thought is
often reflexive, “What right does this person have to do such a
thing?” The second, perhaps something like, “This is insult-
ing.” And the third, “This has to have come from some hateful,
ignorant person.” Rarely however does the finger of responsi-
bility turn in the direction of the other factors that contribute to
the situation, and rarer still does it point toward our own noses.
At this point I ask you to turn your attention to a different real-
ity, the reality of the legal system, perceived over some 18 years
of having practiced law, following a prior longer lifetime as a doc.
7 Some General Legal Principles
7.1 The Sense of the Law: Assuming
It Has Any Sense
Civil law arose as a protective social device, serving initially
to protect the “haves” from the “have -nots.” Laws arose under
the authority of kings, who were also the enforcers and as a
practical matter, the only ones with property to protect. But
when the King of England reluctantly signed the Magna Carta
and relinquished his absolute power, the idea of a changeable,
flexible governance germinated. As democracy evolved, laws
became applicable to everyone and amenable to change.
Legalities reduced to writing and enacted by a legislative body
were termed statutes or statutory law, while rules of conduct
that everyone recognized as customary even without being
reduced to a writing were called the “common law.” Today,
statutory and common law are the axle about which our soci-
ety revolves. Though modified and distinguished over the
years, English law remains the mother to the legal system
practiced in the United States.
English law evolved in the midst of social change and
later came to embrace the notion of protecting the rights of
the few, the weak and the infirm from the abuse of those with
power. Preserving minority rights generally trumped the
alternative concept – the greatest good for the greatest num-
ber. At the same time, certain additional but conflicting prin-
ciples were invoked to protect the health of the state.
Contemporary civil law in the United States is the result of
the vacillation between those several ideals.
7.2 A Word About Language
and Loopholes: The Antithesis
of the Concrete
Language is the alarmingly imprecise tool we use to express
the law, and lawyers are educated to make use of language’s
inherent ambiguity. Examine what follows as an example of
96
how a lawyer, or a judge in this instance, can reinterpret or
even manipulate what might initially appear to be a simple-
appearing, well-articulated statute.
In England, in the year 1965, Fred Ojibway, a man described
as an Indian, was riding his pony through Queen’s Park. Being
impoverished, he had pawned his saddle and had substituted a
feather pillow in its stead. On this particular day, the accused’s
misfortune was further heightened by the circumstance of his
pony breaking its right foreleg. In accord with Indian custom,
the accused then shot the pony to relieve it.
Mr. Ojibway was arrested and charged with having
breeched the Small Birds Act, section 2, which reads exactly
as follows:
Anyone maiming, injuring or killing small birds is guilty of an
offense and subject to a fine not in excess of two hundred
dollars.
Initially, and obviously perhaps, he was acquitted. But
exercising a legal tactic called statutory construction, the
Judge, on appeal, reversed that decision and found Mr.
Ojibway guilty, writing as follows:
Section 1 of the Small Birds Act defines “bird” as a “two legged
animal covered with feathers.” The expert hired by Mr. Ojibway’s
counsel has clearly concluded that the animal in question was a
pony and not a bird. We are not interested however in whether
the animal in question is a bird or not in fact, but only whether it
is a bird, under the law.
In Mr. Ojibway’s defense, his counsel contends further that
the neighing noise this animal emits could not be emitted by a
bird, but with all due respect, the sounds emitted by an animal
are irrelevant to its nature, for a bird is no less a bird if it happens
to be silent. Counsel also argues that the animal was being rid-
den and wore iron shoes. Obviously, this avoids the issue, since
riding a pony, or a bird, is of no offense at all, and how a particu-
lar animal dresses is of no concern to this court.
It remains then to state my reason for judgement which, sim-
ply, is as follows: Different things may take on the same meaning
for different purposes. According to the Small Birds Act statute,
a two-legged, feather-covered animal is defined as a bird. This,
of course, does not imply that only two-legged animals qualify,
for the law appears to make two legs merely the minimum
requirement. I must infer then that the statute contemplated
multi-legged animals with feathers as well.
Counsel submits that with regard to the purpose of the act,
only small animals that are “naturally covered” with feathers
were contemplated. However, had this been the intention of the
legislature, I am certain that the phrase “naturally covered”
would have been expressly inserted, just as ‘Long’ was inserted
in the Longshoreman’s Act.
Therefore, for the purpose of this act, a horse with feathers
on its back must be deemed to be a bird, and it therefore follows,
a pony with feathers on its back is a small bird. The defendant is
guilty.
Lawyers are trained wordsmiths, plain and simple, armed
with a pen and a mouth, doing battle with the imprecise lan-
guage. My point is, loop holes, as we may refer to them, are
inseparable from the legal process because laws are written
using language. We are thus stuck with these words and
N.R. Reisman et al.
stuck with professionals hired by a client with a point of
view to convey. It is the lawyer’s job to zealously accomplish
that end for his client. As you have just seen, words can fail
us and when they do, they can even contradict their more
obvious meaning. The moral of this story for us is, while we
may rule in the O.R., remember the educated power of the
lawyers when playing on their home court.
7.3 The Concept of a Legal Duty
Under the common law of our country, you owe no legal
obligation to remedy anyone else’s distress, regardless of its
form. That premise continues until some affirmative action,
voluntarily taken on your part creates such responsibility.
The shorthand term that describes such a proactively acquired
responsibility is the term of art called a “legal duty.”
If you, a physician, were walking down the street and came
upon someone bleeding from their carotid artery, you would
have no legal duty to save that person from exsanguination.
Under the law you could walk away without penalty. However,
if you stop and begin to help, assuming the absence of a Good
Samaritan statute in your particular state, you acquire a stunning
responsibility/legal duty that you may not have contemplated.
Store owners owe legal duties to the customers who enter
or who buy their products. Parents have legal duties to their
children. Automobile drivers have a legal duty to other drivers
and to pedestrians. In each instance, the possessor of the duty
has done something affirmative to invite a relationship
wherein, in one way or another, they come to occupy the more
“superior” position. Once having done that, their ensuing con-
duct becomes open to the scrutiny of the law, and under pain
of penalty, that conduct must meet certain standards.
As a physician, a legal duty arises when you begin interacting
with any other person in your capacity as a physician. The
moment you begin to “act like a doctor,” the law considers you to
be in a position superior to the layman, and thus able to exert
power and influence. As soon as you open your office door and
tacitly invite the public in, you have, by your affirmative conduct,
created a physician-patient relationship and an attached legal
duty. That duty, like any other duty recognized by the law, if
inadequately fulfilled or “breached,” exposes you to a penalty.
Keep in mind that a physician-patient relationship can
equally arise under unintentional circumstances. While at a
social gathering such as a dinner party, you may think you
are casually giving some medical information to a stranger.
But if that person, knowing and relying on the fact that you
are a doctor, acts on your medical advice, you have created a
physician-patient relationship and spawned an unintentional
but enforceable duty.
How one adequately fulfills a legal duty is a volume unto
itself, but in general, what is owed is “reasonable profes-
sional conduct.”
The American Legal System
7.4 The Standard of Care: Reasonableness
and Negligence
The concept of reasonableness represents the very fiber of
the law and defines the standard up to which conduct is held.
It is a convenient catchall phrase, fictionally created, and ter-
rifically imprecise. Reasonable professional conduct for a
doctor connotes being prudent, careful, taking all the steps
and doing all the things that a “fictional” careful doctor
would do, or not do, all of the time and in every interaction
taken in connection with his or her duty to a patient. If one
fails to live up to that standard of care, the duty has been
breached. Conduct that breaches this “standard of care” is
termed negligent. In common parlance, the closest term to
negligence is probably carelessness. When it comes to satis-
fying your legal duty, the argument, “To err is human,” is not
a consideration.
In many instances, the standard of reasonable care is clear
as can be. If the pathology is in the patient’s right leg, it
would be negligent to operate on the left one. Those instances
are easy. But in many medical situations, the standard of care
turns out to be more of an ill-defined collection of ideas that
defy precise articulation. What, for example, is the standard
of care for cosmetically improving the ptotic breast? In
repairing a cleft lip and palate, is the standard of care to
achieve the best result? Is the best result the best cosmetic
result, or the best functional result, or both? What is meant
by the term “functional result,” anyway? Palpable meanings
can be elusive.
How the standard of care is determined under the law is a
complex matter. Reasonably prudent conduct for a doctor
combines the ideas learned throughout one’s professional
training and experience, absorbed from textbooks, journals,
and meetings, then all that is homogenized with the particu-
larities of the circumstances and the unique nature of the
patient you are treating. The standard of care does not exist
in a vacuum or in any hypothetical situation an attorney may
describe to you.
Keep in mind that the standard of care does not make you
a guarantor of surgical outcomes. “Could you have accom-
plished a more satisfactory outcome ?” is not the issue. There
is probably always more that one “could” have done, espe-
cially in retrospect. The legal standard is rather, “Did you do
all the things that a reasonably prudent but fictitious plastic
surgeon would have done under the circumstances?”
7.5 The Expert and The Standard of Care
Experts appear in every medical malpractice case, and it is
the experts who define the standard of care since the standard
can vary with the particularities of the circumstances. One
might ordinarily expect then that an expert would be a
97
thought leader in a field, someone highly regarded in his/her
area of expertise, possessing remarkable credentials. But in
the context of the law that is not the case. In a legal context,
an expert is someone with sufficient credentials, meaning
knowledge and/or experience, whom the judge deems capa-
ble of assisting the members of a jury in giving clarity to the
technical issues in the case and in identifying for the jury, the
standard of care. A gas station operator may be nominated an
expert in the field of changing flat tires, though not one in the
field of tire manufacture and design.
In a medical malpractice case, each side is obligated to
present expert testimony. Every plastic surgeon, by training
and experience, is an expert in the field of medicine in gen-
eral, and certainly in the general area of plastic surgery. It is
for the jurors to weigh the credentials of each expert and they
are instructed by the judge to give relative weight, if they
deem it appropriate, to what one expert says as compared
with another. The length of an expert’s resume may be given
less, more, or no weight at all. That is up to each juror to
decide. But in the end, it is what the experts say or cite at trial
that defines what the standard of care was in a particular
instance.
In a medical malpractice case, each side, plaintiff and
defendant, is obligated to present expert testimony regarding
three questions – what was the standard of care, was the stan-
dard breached, and if so, what damages were suffered as a
consequence. Usually, the court only allows one expert to
testify for each side regarding each question. In a medical
malpractice case, however, the physician defendant has a dis-
tinct advantage. The plaintiff may bring only one expert’s
testimony to bear on each of the three trial questions. The
defendant is also permitted to engage experts. But because
the defendant physician is automatically deemed an expert in
his/her field, and because the defendant has a right to testify
on his own behalf, the defendant physician in effect has the
benefit of two experts to speak to the jury about each of the
questions. It stands to reason that jurors will be more apt to
believe something when they hear it “time and time again.”
7.6 The Burden of Proof
Our legal system goes out of its way to give those with griev-
ances the opportunity to be heard, but not without burden or
limitation. Breaking in tradition with our English roots, where
the loser of a lawsuit has to repay the winner’s expenses, our
jurisprudence lays the economic burden on each of the con-
testants, so if you lose, you just lose only your own invest-
ment in the case. Were this not the case we argue, no plaintiff
could, as a practical matter, risk filing suit against any party
with sufficient means to bankrupt the plaintiff’s efforts in the
event of a loss. Such a threat, we believe, would bring an
unpalatable chill to the system. Of course, this point of view
98
comes with its own painful detriments. Paired with this is the
notion that our lawyers serve as private attorney generals,
who, while motivated by profit, will expose evils, which the
system might not otherwise recognize or pursue. This laud-
able premise brings its own tragedies. In the end, these com-
peting interests are tolerated as balanced trade-offs.
As part of the balance, the law imposes a time limit on
plaintiffs. In most jurisdictions, the statute of limitations
where a person is physically injured, is 2 years The underly-
ing principle is that over time, memories fade and evidence
erodes. In addition, it is felt there has to come a time when
the consequences of ancient conduct cease. So arbitrarily, a
2-year limit in connection with personal injury matters has
been adopted (Statutes of limitation of up to 6 years often
pertain to some contract issues). Minors, being among the
weakest and therefore the most favored in our system, usu-
ally have their statute of limitations put on hold (or “tolled”
in legal terms), until they reach the age of 18, giving them
until age 20 to complain. On the other side of that coin is the
obstetrician who, 20 years after delivering an infant, faces
what the law considers a timely suit. As you can see, balanc-
ing interests that are competing for justice can create very
unsatisfactory outcomes.
Once gaining access, the plaintiff must bear what is
termed the burden of proof or the burden of persuasion. In
criminal matters, where the defendant’s liberty is at stake,
the burden of persuasion borne by the state, the plaintiff in
that case, is correspondingly very high. Here, the state must
convince the jurors beyond all reasonable doubt and by a
unanimous vote.
In civil matters, the stake is merely money and the burden
correspondingly lower. The plaintiff’s burden in a civil matter
is to convince the jury only that his version of the facts is more
believable than the defendant’s, and the plaintiff prevails even
if the scale tips only slightly in his favor. If the jury thinks that
the defendant’s version was more believable or that the argu-
ment ended in a tie, the defendant wins. In addition, with the
usual 12-person civil jury, the plaintiff has to convince 10 out
of the 12 of his version. Even a vote of 9 to 3 in plaintiff’s
favor produces a hung jury, under which circumstance, in a
sense, the defendant prevails, subject only perhaps to a retrial.
In return for shouldering the burden of proof, the plaintiff does
get a few technical concessions at trial, among them getting to
present his case first and lock in a point of view.
7.7 You’ve Been Sued: Now What?
The Complaint – What Is My Name
Doing on This Thing?
To the uninformed the complaint can be a foreboding docu-
ment, loaded with legal mumbo jumbo and unflattering state-
ments. But beyond its intention to intimidate, the complaint
N.R. Reisman et al.
is actually the blueprint for the entire case. It is in essence a
letter to a judge, written in an arcane but traditional style,
explaining the reasons for the suit and why plaintiff should
prevail.
Several things about the complaint are worth examining.
Why is it, for example, that doctors are often named as
defendants in a medical malpractice case when in fact they
had nothing to do with the outcome? The first answer is that
the attorney who drafts a complaint usually does so with the
benefit of only the client’s story and the medical records (We
all know by experience how difficult it can be sometimes to
read physician’s handwriting.). Since there is usually not
much of a downside to including a defendant or two and dis-
missing them later, legible names in an otherwise undeci-
pherable record often wind up as named defendants. The
havoc that mischief produces in other people’s lives is not
usually a factor that is even reflected on.
A second reason for being wrongfully named is that law-
yers are subject to malpractice suits too, and the failure to
include a culpable defendant may doom a case before it
begins. The lawyer has only up to the statute of limitations to
file or later amend his complaint, and not infrequently the
client shows late in the game. Obtaining, then deciphering
the records, finding an expert, getting copies of the records to
the expert, obtaining the expert’s reply, and then trying to
interpret what the expert had to say is extremely time-
consuming. Very few attorneys are well versed in medicine
and very few experts express themselves in words most attor-
neys can readily understand. For the plaintiff’s attorney, the
process is slow, expensive, and uncomfortably uncertain.
When I first started practicing law I hesitated to name
house staff as parties. They were early in their careers, didn’t
need a strike against them, and the liability for their actions
could easily be deflected to the attending physician or the
hospital. I quickly learned however that doctors in training
move around a lot, and locating them and having them return
from wherever they now reside to have their deposition
taken, proved to be both time-consuming and expensive. On
the other hand, if they are named parties, it becomes the hos-
pital’s obligation to find them and get them to the deposi-
tion – at their expense, and not mine.
Lastly, lawyers often include as named parties people tan-
gential to the issue in an effort to obtain pressured but other-
wise unobtainable “honest” testimony in exchange for that
physician’s dismissal from the action. Under certain circum-
stances, this morally underhanded tactic proves very effective.
7.8 Discovery and Some of It’s Mechanics
Once the issues in a lawsuit are “framed” by the pleadings,
which include the complaint and the defendant’s answer to
it, trial looms somewhere in the future. It was not that many
The American Legal System
years ago that trials were conducted by ambush. Suit was
filed as it is today and the parties were assigned to the judge
who would preside at a trial scheduled to take place months
to years later. But until trial, the opposing attorneys worked
on their cases fairly independent of each other, without an
obligation to disclose much of anything about their case or
the ability to learn anything about the opponent’s case. What
little information they were required to exchange, and there
wasn’t very much, usually required a fight, refereed by the
assigned judge. So except when the opposing attorneys met
for lunch (as they used to in the “old days”), and unofficially
whispered mischief into each other’s ears, the two cases were
complete strangers to each other. As a result, unless the attor-
neys were friends or cooperative adversaries, there was little
chance to learn the opponent’s position, convince the oppo-
nent of the strength of your position and as a result, little
chance to resolve the case short of the jury’s verdict.
Over time, the system sought a mechanism to facilitate
settlements, rather than force the resolution of cases solely
by trial. The result was the process called “discovery.”
Through a variety of mechanisms, discovery requires the
opposing parties to exchange information sufficient for each
side to learn their opponents’ strengths and weaknesses. At
the same time, the attorneys are given general control of the
discovery process, eliminating the judge from most all of
the pretrial process and allowing them more time to hear
criminal matters.
7.9 Interrogatories
Interrogatories are written questions, which a party may
compose and submit to another, to be answered under oath.
But drafting questions with language sharp enough to com-
pel the opposing lawyer to provide a straightforward answer
turns out to be much more difficult than you might imagine.
Questions posed for the purpose of learning, for example
who was in the room or on what date some event took place,
are well suited to such a format. But questions that ask “why”
or contain words that wordsmiths can manipulate, make this
form of discovery of relatively little value in medical mal-
practice cases.
7.10 Requests for Production
and Entry Upon Land
A party may obtain any documents not protected by privilege
from another party by simply requesting them. If a particular
surgical instrument you own is part of the case, that too can
be similarly requested for production.
If an event took place in your office, and the configuration
of your office space could be a consideration in the case, an
99
opposing party is permitted an enforceable request to come
and enter upon your land, so to speak, and view the premises
at your convenience, by appointment.
Keep in mind that anyone subject to a discovery request
has the right to object and provide the grounds for the objec-
tion. At that point, the request is frozen until the Court, on
being made aware of the objection, hears the objection and
rules on its validity by supporting or overruling it.
7.11 Requests for Admission
At any point in the case, a party can submit to another a state-
ment or group of statements called Requests For Admission.
Generally, each request is formulated as a single sentence.
The recipient is obliged to answer each statement with either
an admission or a denial, but may supplement their one word
response with an explanation. In general, it is best to offer as
little as possible about anything within the case, since what-
ever you say has the potential to be turned around and con-
strued by your adversaries to their advantage. Understandably,
opposing counsel always invites unsolicited information.
Requests For Admission are usually sharply defined state-
ments, whose answers can be read directly to the jury as
statements you embrace or deny, with little or no opportunity
for further explanation right then and there. Obviously, they
should never be answered without consultation.
7.12 Depositions and Related Stuff
The last of the usual discovery mechanisms is the deposition.
This exercise pits an attorney against a witness (the depo-
nent) who is under oath, in a question and answer setting.
Unfortunately for the witness, only the attorney gets to pose
the questions. At the witness’s option, representation by
counsel is permitted. Even if you are having your deposition
taken in a case where you are not a party, you should have an
attorney with you. As a rule, your malpractice carrier will
provide one for you at no charge even when you are not
named in the suit.
A court reporter or stenographer records the Q & A dia-
logue, and is often capable of generating a complete type-
written transcript of the entire session almost immediately.
In the ordinary course of events, a copy of the transcript is
sent to the deponent a week or two later, for an opportunity
to approve the transcript’s accuracy. A page for the depo-
nent’s corrections, called an errata sheet, is included for that
purpose. Generally speaking, the witness should read the
transcript and before signing it, consult with his/her attorney.
Wholesale corrections are not permitted except where there
has been a clear transcription error. So you really have to get
it right the first time around.
100
For the attorney taking the deposition, the exercise is a
relatively free-wheeling event that requires a lot of prepara-
tion, since a witness is usually obliged to only have his/her
deposition taken once in the course of a case. When prepar-
ing the deposition, the plaintiff’s attorney has several things
in mind. First, every aspect of the case has to be dealt with.
Second, depositions present an opportunity to explore the
witness’s opinions as well as the facts, and the opportunity to
do so beyond the hearing of the jury. Third, depositions pro-
vide an opportunity to evaluate the deponent’s personality or
demeanor, how he or she responds to questions, and whether
it is possible to get the witness upset in a way that can be
utilized at a later time. Very often, decisions about the entire
case turn on how the deponent “looks” and responds under
fire. Know too that it is not just opposing counsel who is
evaluating your performance. So too is “your” attorney, who
is usually obliged to submit a written report within a day or
two to his or her true employer, the insurance company,
describing how you performed. It is strongly recommended
that you be tastefully attired and on your disarmingly best
behavior when you show up and testify at your deposition.
Leave the jewelry and the scrub suit home.
Because the deposition “interview” is under oath, any por-
tion of the dialogue is subject to being quoted during the trial,
so listen carefully to what you say during a deposition, because
there is a reasonable chance you will hear some of those same
words again. Changing your mind in the meanwhile doesn’t
usually work very well, because if you do, you can expect
opposing counsel to read the answer you gave during the
deposition and ask, “Well now doctor, which time were you
telling the truth, just now, or during your deposition?”
In most depositions, the physician witness knows much
more about the medicine and the facts of the case than the
attorney asking the questions. The pitfall is that you may be
inclined to rely on that notion and prepare poorly or not at
all. Add to the lack of preparation the fact that a deposition is
occasionally a word game, played between you, the amateur,
and a professional, and it becomes apparent that you can
quickly become painfully overmatched. Your strongest
defense lies in your being properly prepared by your lawyer.
Or is it really YOUR lawyer?
Consider this. If you pay premiums to your insurance
company and the insurance company selects and pays the
lawyer or law firm that represents you in your malpractice
case, to whom are your lawyer’s loyalties owed? To you? Or
to the insurance company that is paying the freight and will
also be the source of your lawyer’s future income? Common
sense tells you that at best, the loyalties are split. This mixed
loyalty issue becomes especially worrisome when the time
comes down the line to consider whether to settle your case or
move forward to trial. Your point of view counts, of course,
but is your “insurance company-paid lawyer” looking out for
your best interests or his employer’s, when giving you advice?
N.R. Reisman et al.
On a related note, be aware that the attorney who accom-
panies and prepares you for your deposition is usually not
the one who will represent you at trial. The trial guys are the
few senior people in the firm – the attendings, so to speak.
Your deposition counsel is usually one of the junior associ-
ates at the firm, something akin at best, to a chief resident.
Insurance companies often pay defense law firms by the case
or on an hourly basis and a defense law firm’s profits lie in
part on volume, and in part on billing at senior counsel rates
while using junior counsel as much as possible.
While it may momentarily seem that the insurance com-
pany’s appointed lawyer comes to you free of charge, please
recall all the premiums you have paid over the years for this
free lawyer. Understanding that you are even more than a
full-paying consumer, it is suggested that you act accord-
ingly when confronting your appointed counsel, and not just
take whatever you are offered. Early on, insist that you meet
with senior trial counsel, and if the particular lawyer you are
offered at the outset does not engender your complete confi-
dence, insist someone else from that firm or tell your insur-
ance company to find a different one. After all, you have
been paying for this representation for years.
Your best defense to being overwhelmed in a deposition is
preparation, something your attorney should have empha-
sized long before it takes place. Even though you may have
been the author of most of the records in the case, you should
review them with scrutiny both to refresh your recollection as
well as to see what the language you used actually says, as
compared with what you believe you wanted to convey. Then,
teach the case to your lawyer, who if you will recall, is only a
lawyer. Remember that your opponent will have probably
out-study and out-prepare you by a factor of 4:1. Plaintiffs’
lawyers usually have many fewer cases than defense lawyers
and they win only if you lose. Next, be sure to review all
potentially unsettling questions and problem areas with your
attorney during the course of at least two preparatory sessions
held well before the day of the deposition. Never be satisfied
with a single prep session held the morning the deposition is
to take place. If it seems things are aiming in that direction, it
should tell you something important about the caliber of your
lawyer and his or her dedication to outcome.
7.13 Trial
There’s not much one can say briefly when it comes to
describing a medical malpractice trial. There are however
some overriding concepts that are probably worth mention-
ing, the most important of which is contextual.
Trials are not recreations of an M & M (morbidity and mor-
tality) conference. Whose information comes from the most
recent literature or best chi-square statistical analysis are not
even considerations, let alone factors in deciding who wins. If
The American Legal System
a medical malpractice trial does seem to be focused for a time
on scientific principles, it is likely you just walked in at an
unusual time. Instead, trials are theatrical events where you are
both the producer and one of the starring actors.
The earliest inklings of the script for this theatrical drama
appear in the complaint, but that really just constitutes at best
a sketchy outline. Most of the actors’ lines are developed
during discovery, with the parties’ deposition testimony and
experts’ reports defining most if not all of what will be said.
The directors are the trial lawyers representing the plaintiff
and the defendant. The starring actors are the plaintiff and
the defendant, with supporting roles filled by the experts and
the family members who invariably appear on the plaintiff’s
behalf. The judge is the critic who has no real purpose in a
jury trial other than to express criticism for the manner in
which the actors’ lines are delivered, much as a referee
would. Beyond that the judge really does not play a role. Last
comes the jury, the viewing public, who decide which part or
parts of the show they find most appealing. So at the end of
the day, it is only the jury, the audience, the 12 people from
off the bus stop as I prefer to describe them, who count and
no one else. They must be informed, appealed to, pampered,
cajoled and indulged, and it is your obligation as the pro-
ducer, to make the show work, since it is you who will either
reap the rewards or suffer the show’s failure.
What does all this mean to you? First Mr. Producer, you
have to pick the right director and not be afraid to hire a new
one if need be. Next you must assist, hands-on, in developing
and writing the script, because in the end, all you have hired is
a director, not an author. Once you write or develop the plot, it
is your obligation to teach it to your director, whose knowledge
of its substance usually pales in comparison to yours. Next
comes assisting with the selection of the experts, your support-
ing actors, and writing or assisting in the writing of their lines
and yours (I know you have a life beyond this hypothetical trial
but how severely will it be impacted if the show fails?).
These were the preliminaries. As opening day arrives, you
have to be prepared for show time and be emotionally settled.
Your lines must be rehearsed and be fluidly and fluently pre-
sented (In English, not doctor-talk). Dress respectfully and not
with flamboyance or casual comfort. Present yourself confi-
dently but not smugly, and remember to speak to the audience
slowly and methodically, without focusing your attention in
the direction of the directors or the critic unless necessary.
In the final analysis, if the crowd likes you, you win. If
they don’t, you lose. It often has little if anything to do with
medicine. That’s trial.
7.14 Business and the Insurance Business
Before jumping in over my head, appreciate another basic
principle that drives our system. It is one that to our detriment,
101
evolves from an illicit/immoral but invisible three-party mar-
riage comprised of the insurance industry, the law, and our
governments’ financial interests.
When our Constitution was written, the concept of federal
social programs to serve the nation’s “needy” citizens was
nonexistent. So it was only one state or another that decided
whether social programs were indicated, and it was only on
the state level that such fiscal responsibility existed. Early on
there was little such interest, but over time various state-
sponsored social programs did arise. Many decades passed
before the federal government acknowledged this need and
began granting monies to the states to reimburse their wel-
fare programs.
Benevolently, those who failed in life for one reason or
another became quasi-wards of the state, receiving dis-
counted or free food, shelter, and/or medical care. Initially,
such programs were few and not particularly onerous. At the
same time, the government considered the infant insurance
industry a business like any other, and extended that industry
no considerations on the basis of social issues. Somewhere
around the turn of the twentieth century, the insurance indus-
try began to grow at an astounding pace, the concept of
insurance took hold, premiums seemed fair, and the profits
for prudent insurers proved to be astronomic.
Over time, government took a belated look at this bur-
geoning business and decided it was in the nation’s interest
to give it favor, as only our government can when it wants to.
As our legislators and judiciary saw things, if the economi-
cally strong manufacturers and wholesalers, who were in the
best position to purchase insurance, were “compelled” by
circumstances to do so, the state and federal governments
could avoid the burden of supporting those whose injuries
arose as a result of “insurable situations.” Insurance became
the nation’s economic savior. Big Insurance had arrived. My
friends, let the games begin.
If any product malfunctions and causes harm to its user in
any reasonable way, the manufacturer of the product, along
with any person or entity that moved that product along in
the course of commerce, is responsible, or liable, for all the
adverse economic consequences – the physical harm, the
medical expenses, the lost income, and all the future conse-
quential losses you could conjure. The concept is called,
“product liability,” and it is a basic principle of American
law. Why? Because, as the reasoning goes, between the
profit-making manufacturers/wholesalers and the innocent
consumer, it is those with commercial interests who are in
the best economic position to procure insurance and bear the
burden of any future loss through injury. Plus, the cost of the
insurance can be built into the product’s price, so the con-
sumers as a whole indirectly pay the cost of the insurance,
leaving no burden on industry.
Would you like to sell a product that the law says every
manufacturer must buy or bear exposure for? The overriding
102
concepts of course are based on the premise that successful
insurance companies are a good thing.
As another example, consider that every “economic gain”
you accrue is taxable, especially windfalls and short-term
gains, which are often taxed even more heavily. On the other
hand, by federal law, life insurance benefits are exempt from
taxation. Interesting concept, no? What an admirably devi-
ous way of preventing the decedents’ survivors from becom-
ing “wards of the state,” while concurrently enticing citizens
to invest in life insurance – to the benefit of both the state and
the insurance companies. It is somewhat disquieting to learn
how the insurance business became increasingly successful
through federal legislation.
To balance things and protect the populace from the insur-
ance companies, state governments interpose themselves
between the companies and the consumers by “regulating”
the insurance industry. Insurance companies are obliged to
apply to a state to do business with its citizens, and must
obtain permission to increase rates. But at the end of each
year, when paper losses exceed the prior year’s projections,
states virtually rubber-stamp premium increases to cover the
losses and assure the next year’s profits (In the meanwhile,
the monies set aside by the industry as “reserves” to pay
future claims are hard at work as unrecognized but lucrative
investments.). The insurance industry is as close to a func-
tioning monopoly as any in our country, and has as much or
more influence in Washington than all the oil and pharma-
ceutical interests combined.
At trial, it is universally considered an absolute taboo to
even mention the existence of insurance to a jury. Why?
Because, it is argued, jurors have less compunction about
weighing in against an individual than they will if they know
the responsible party was actually an insurance company. So
to protect the insurances companies, there exists a legal “fic-
tion” – for the purpose of trial, there is no such thing as an
insurance company. Would you like to be in a business where
the law shields you from losses?
Have you ever encountered a problem getting reimbursed
by an insurance company – for a fee, or as a consequence of
an insured loss? It is often not very easy to get an insurance
company to “disgorge” honest reimbursements, is it? It
becomes easy to see then that insurance companies, the own-
ers of more real property in this country than any other entity,
are really not in the insurance business at all. They are in the
money business.
As long as interest rates, the stock market, real estate, and
other financial sports remain healthy, there is no insurance cri-
sis. “Just pay the premiums and well put ‘em to work” is the
silent mantra. The focus is not really on actuarial calculations
based on insuring conduct. Insurance company profits are
derived from investing the premiums, hiding the “reserves” in
profit-making forms, and raising rates with the state regula-
tors’ okay. So periodically, when the financial industries go
N.R. Reisman et al.
dry, premiums rise (never to fall again), the patients get
pinched, the doctors get squeezed, the lawyers become the vil-
lains, and we leave one state and flee to another. Basic societal
rights may get sacrificed but insurance company profits are
preserved. Who is getting the free ride here?
We also seem to forget that when insurance carriers arbi-
trarily denied or withheld adequate payments for physician
services, it was the lawyers we hate but hired, that recovered
at least some of what we were owed. The system moves
slowly but if not for the lawyers, who are in a position to
keep things in balance and protect us, the individuals, from
the system? No one likes lawyers until you need one.
The Blues of Pennsylvania, where I reside, are reported by
their own suspect admission, to currently have a $4 billion sur-
plus (I said billion). On inspection, they have also recently been
accused of “hiding the profits they generate from the ancillary
for-profit businesses they operate....exaggerating the extent of
their charitable contributions, and failing to respond to finan-
cial reporting deadlines.” Nationwide, HMO stock prices con-
tinue to rise while this approximate $80 billion dollar a year
enterprise remains supported on the physicians’ backs.
We respond to Big Insurance by creating equally dishon-
est Big Medicine. In December 2004, the Associated Press
reported that Gambro Healthcare USA, the third-largest
operator of renal dialysis clinics in the country agreed to pay
$350 million to settle (that’s settle mind you, without
acknowledging guilt), claims of defrauding Medicare by
“paying kickbacks to physicians for referrals, setting up a
sham company to feed inflated billings to Medicare, and
falsifying billing statements to patients to justify compensa-
tion for unnecessary tests and services.” And all we argue is
that medical costs are rising because we are obliged to prac-
tice defensively. Give me a break.
7.15 Physician Economics: The Seeds
of Change
Drastic changes in physician economics began in the late
1950s or early 1960s, when our forefathers first welcomed
Medicare into their offices. Medicare was seen as a lucrative
solution to all the “no-fee” elderly patients we had been
treating since time immemorial, treated in return merely for
deeply expressed thanks, and the appreciative pot of soup or
cookies these elderly patients often brought to the office.
Doctors felt good about providing that kind of service, and
so too did the public. Professional fees were often in the
form of cash (that may or may not have been unreported as
income), and most of the doctors’ wives owned and openly
wore their fur coats to country club affairs. Everyone was
winning and at no one else’s apparent expense.
But the government had an undisclosed long-range plan
that would take its final form only after creating a decade or
The American Legal System
two of new-found wealth and physician comfort. At about
the same time, the insurance companies, with a similar long-
range agenda, gained similar entry. Their deal was, send us
the bills and we’ll pay you directly, with no need to involve
the patients with reimbursement details. This promised less
bookkeeping, timely cash flow, and the avoidance of
instances where the patients were paid by the insurer and
then “forgot” to pay the doctor. Physicians celebrated the cir-
cumstances by raising fees at a rate of about 15% per year,
year after year. I remember those times well. They were the
Golden Years during which the goose continued to lay
golden eggs. But he who laughs last…
Once inside the office door and installed as an integral
part of the system, the insurers, including the “privates,” the
“Blues,” and Medicare, slowly began to flex their muscle.
First, Medicare began setting a fee structure, and in the
beginning, it was perhaps one we felt we could live with.
Before long however, the government cried poverty and
Medicare’s payment schedules fell. If the doctors were will-
ing to take less from Medicare, then it made sense for the
other insurers to tie their remuneration schemes to the lower
Medicare standards of pay. In time, the HMOs arrived, with
rewards for restricting testing and consultations. While the
GPs scrambled to sign up for their bonuses, the competition
for HMO slots drove down the prices doctors were willing to
work for. Again and again, short-term economic gains
evolved into endless downward spirals.
In my experience, physicians have always been short-
sighted, driven by near-term pocketbook considerations,
individuality, and large egos. We’ve never operated or coop-
erated as a group and seem to never be able to reach a con-
sensus on goals and stick to them. Dentistry, by comparison,
seems to have done a remarkably better job of creating a
silent unity against the inroads of Big Insurance.
In a free marketplace, rising overhead, which includes
malpractice premiums, can be offset by a comparable rise in
fees, but as things have evolved, most of our brethren remain
hitched to the unyielding fee ceiling called “plan participa-
tion.” Maybe it’s time to unhitch, as a group, but silently so
as to avoid the appearance of illegal collusion. (What a
joke…everyone is in collusion against the physicians but we
are precluded by law from responding as a single voice.)
7.16 The Crisis: The Crises
Crises abound – for us, for our patients, for our families, and
for the healthcare – delivery system we are part of, but with
which we have lost all measure of control. At the same time,
the only medical issues that capture the public’s attention are
those featured in the media story du jour. Digging our way
out of the hole we are in requires first that we identify the
enemies who dug this trench.
103
8 The Cast of Enemies
8.1 The Trial Lawyer: The Obvious Enemy
Like physicians, the trial lawyers are by no means a homoge-
neous group. There are probably too many of them and like
us, they have little collective unity. Their intellectual capaci-
ties fall into the same range of mediocrity we recognize in
our own profession, since one-third of them too graduated in
the bottom one-third of their class.
Lawyers do little if anything to police their own and what-
ever conscience an individual lawyer may have is intermit-
tently subsumed by the need to zealously serve the client at
hand, whether of pure or impure aspirations. The system
favors lawyers because they are the ones who both write the
laws and are trained in the art of manipulating them to their
advantage. The good news is that lawyers are ultimately flex-
ible, so changing anything with a trial lawyer’s assistance
never presents a conflict of interest.
Trying to modify what individual lawyers do is probably
an exercise in futility, since lawyers are folks who generally
do whatever the system requires, condones or lets them get
away with. While there are certainly more than a few lousy
and disreputable ones, sharp rules for eliminating the unscru-
pulous lawyers from the system are probably as inequitable
as similarly suggested sharp rules for eliminating “problem”
doctors. The lawyer who filed suit against you wears
underwear and has unresolved issues with parents, just as we
do. Weeding out the bad apples in the legal profession may
be as difficult as the job we face in weeding out our own.
One thought with regard to the individual lawyer is the
suggestion that he or she ought to be required to possess
some specialty credentials to bring a medical malpractice
claim. Mostly, every hospital in our country no longer per-
mits family practitioners to meddle in the ICU, and obtaining
surgical privileges to do hand cases requires more than just
requesting them. The vast majority of lawyers are poorly
equipped by training and experience to appreciate the com-
plexities of almost any medical situation, yet there is nothing
to prevent even the least capable from disrupting the system
with a baseless suit, hoping for a fear-ridden settlement.
In a similar vein, the legal system recognized many years
ago that certain areas of litigation, because of their special-
ized and/or refined nature, require special courts, specialty
trained lawyers, and special judges for settling differences.
Nearly 100 years ago, special federal courts were established
with jurisdiction over issues regarding patents, trademarks,
and copyright. We have special courts to hear bankruptcy
issues as well. Is it reasonable to believe that the ordinary
court with a politically appointed or elected judge is capable
of grappling fairly with the concept of a TRAM flap and
what the standard of care requires? In my experience, the
question isn’t even close.
104
The time left for us to spend with patients one-on-one is
being eroded every day, and what we need least are distractions
from people who frankly, have no clue. Things have changed
and in this regard, the legal system has not. But as a practical
matter, changing what we do and bringing attention to the other
players in this game is probably the more productive way to go.
8.2 Your Office Staff: The Invisible Enemy
The people who staff your front desk and answer the tele-
phone often generate the added friction that can initiate a
malpractice claim, especially the kind that are petty and
baseless. Sick people and those caring for them are agitated,
upset, and easily annoyed. It also goes without saying that
cosmetic surgery patients can be inordinately demanding
and irritatingly trivial. Overall, dealing with patients’ prob-
lems and concerns as early as possible will tend to cool
upsets that might otherwise linger and grow.
To the patients, your staff is you. A kind word or a pause
to listen to a senseless telephone conversation can go far in
defusing an irritation that may have innocently been kindled
by a minor wound infection followed by 20 minutes on hold
on the phone. The staff should also be encouraged to be your
eyes and ears, and let you know which patients they have
recognized as potential problems, even before you do.
You should identify problem patients to your scheduler
and have “special” patients seen at “off” hours or at the
beginning of the office day. Recognizing they are being given
special treatment may make someone more likely to be
appeased rather than cranky.
Remember too that although the staff may be transient,
while in your employment they learn some very intimate
things about you, your patients, and how you conduct busi-
ness. Some of what they come to know would play poorly in
a court of law, and under the law, when they screw things up,
you could be legally responsible for their carelessness. No
employee is family and every employee has to be trained and
retrained at times in the ways you want patients handled. The
front desk can make you or break you. A monthly meeting
with the entire staff in attendance, even for a few minutes,
can be a very productive use of the boss’s valuable time.
8.3 The Patients: The Most
Apparent Enemy
Patients are your simultaneous raison d’etre and bane of your
existence. They represent the joyous reflection of your work,
the source of your income, and much too often, the annoying
so and so’s you have to deal with. I have heard, “Practicing
medicine would really be fun if it weren’t for the people you
have to deal with.” As the plaintiffs in the lawsuits you face,
N.R. Reisman et al.
patients are clearly high-ranking enemies. And to make mat-
ters worse, the media, in conjunction with some of our col-
leagues, have raised patients’ expectations to unrealistic
heights. But since dealing with patients is an unavoidable
necessity, recognize there is a degree of prophylaxis that can
prevent some heartache before it begins.
Most importantly, recognize that you cannot be all things to
all people. There will always be people who you do not like
you, people with hidden agendas, and people that no one can
constructively contribute to. If after an initial office visit some-
thing just doesn’t “feel” right, trust your judgement and decline
the case. Avoid the patient who comes with a minimal defor-
mity joined to a maximized concern. As often said by a former
mentor, don’t let the jingle in your pocket create a jangle in
your life. Trust your sixth sense and take direction from it.
8.4 Is the System the Enemy?
The circumstances that physicians find themselves in today
are the end result of a misdirected and somewhat upside-
down system. But which system? I do not believe the pri-
mary fault lies with our system of laws. Today’s morass
represents the end point in the natural history of intentions
originally dedicated to “taking care of sick people” that
mutated into a dedication to profits.
When the practice of healing became the business of med-
icine, everything changed. Patients became customers, doc-
tors became providers, insurance giants became healthcare
companies, and upsets became law suits. Consistent with
their acquired business-like posture, physicians became
caught in legal mechanisms designed for commercial con-
flicts and motor vehicle accidents, not the necessities of car-
ing for the sick. If you are sick about the state of medical
malpractice, consider how sick the people are with what the
practice of medicine has become.
A prescription drug is manufactured in Ireland and
shipped to the USA for sale in Peoria at a price of $2 per
tablet. The same drug is shipped from the same Ireland
address to Canada, for sale in Vancouver at a price of $1 per
tablet. The “Healthcare-Industrial Complex” that protects
the profits of Big Business in this country insures this dispar-
ity and manages through its lobbying efforts to forbid US
citizens from buying prescription drugs “abroad,” arguing
they may not be safe. It’s a lie that cheats sick people, but a
practice that is good business. Good business and good med-
icine are generally mutually exclusive considerations.
The underpinnings of how physicians are perceived lies
with the practice of family medicine. Finding abnormal
blood test results and pursuing them is a lucrative business.
Preventing disease through heartfelt counselling is not.
Spending time with patients taking their histories and
inquiring about all the important aspects of their lives are
The American Legal System
activities that do not bill very well, but writing prescriptions
and getting people out of the office quickly promotes eco-
nomic efficiency. A family practitioner used to make a rea-
sonable living seeing 3–5 patients per hour, charging his fee
and collecting it or not, by himself. The family doctor knew
every patient by name, had a trusting rapport with every
one, and even knew when one of his flock “didn’t look
good.” Under HMO capitation, the same doctor sees at least
three times that number of patients per hour, has two clerks
who do nothing but fill out forms, and has an income that
when adjusted for inflation, falls each year. The doctor and
his three partners write notes in patients’ chart but have no
time to discuss the patient with each other or with the patient
for that matter. The “one hand on the doorknob” office visit
has become the norm.
The parties to the healthcare pact have become strangers
to one other, and they interact as strangers as well. Friends
rarely sue each other for errors, real or perceived. But in the
year 2005, commercial, adversarial strangers sue each other
at the drop of a hat. The degree to which the relationship
with our patients has become estranged matches the inci-
dence of newly filed lawsuits. The doctor’s office is no lon-
ger a place where trusted friends meet. It is now merely a
profit center where a commercialized professional tries to
maximize the bottom line. The bond between the patients
and the doctors which was You and Me has become You or
Me, and the public has responded accordingly. It’s time for
something to change.
8.5 Pogo
Those of you old enough to remember the comic strip named
“Pogo” will recall the main character’s famous line, “We
have met the enemy and it is us.” This is not to say that we
have created the unbearable circumstances that characterize
our lot today. Unfortunately, we have acted as we always
have – as egocentric individuals whose sole objective has
always been short-term self-preservation. We are responsible
for the mess to the extent that we have stood by and silently
let it happen.
If we are truly looking for constructive solutions, let’s
first be honest. There is a wealth of iatrogenic illness out
there and we have to acknowledge that mistakes happen in
the context of patient care – doctors are human. We all make
mistakes every day. A 1999 report by the Institute of
Medicine, whoever that may be, said mistakes kill as many
as 98,000 hospitalized Americans each year. While there
exists a small percentage of physicians who repeatedly
break the rules and practice in an ignorant fashion, we gen-
erally know who those doctors are and as a group, turn a
blind eye toward them. When mistakes surface, doctors are
notorious circling the wagons and hiding the truth instead of
105
coming forward with integrity and an apology. This sort of
conduct supports the “You or Me” mentality that has lead us
to where we now stand. Yet we teach our children to apolo-
gize when they hurt someone else, even before we teach
them the ABCs.
There are constructive steps you can take to at least mini-
mize the potential of becoming a defendant in a medical mal-
practice suit. Patient selection, as described above is one.
Another is taking advantage of the so-called “informed con-
sent” conversation. If you have discussed common post-op
complications like wound infections with patients in some
depth before they occur, you appear intelligently prophetic
when the wound gets red and tender on the fourth postopera-
tive day. On the other hand, trying to explain that wound
infection to your patient after it occurs will most often sound
like you are making an excuse. Overall, recognize that the
more time you spend with the “problem” patient, the less
likely that person is to visit a lawyer for the purpose of ven-
tilating. Abrupt dealings with patients, especially those agi-
tated about things you may consider trivial, often trigger a
backlash that costs you more time in the end. Most physi-
cians unconsciously try to avoid seeing the unhappy patient
with complications, even when the complication occurs
without fault. But as one plastic surgery mentor has astutely
suggested, do the opposite. See the unhappy patient over and
over and over again, to the point where they apologize for
taking up so much of your time. Preventing a lawsuit is a
much easier and less time-consuming task than dealing with
one once it has begun. When you spend time with people, the
perception is that you care. Overall, doing what it takes to
demonstrate that you care is probably the key prophylactic
measure when it comes to preventing litigation.
While it is often easy to conjecture short-term solutions to
offensive litigation, it is important to maintain a global view
with respect to the overall values our system protects. Every
time we voice outrage and want to tinker with the system,
remember that in all likelihood, each of us will likely be a
plaintiff at some point. So go slowly before suggesting that
the loser in a civil suit should pay the winners’ costs.
There is obviously a wealth of imbedded problems. The
bad news is that as individuals we are trapped and controlled
by considerations, mainly economic, over which we seem to
have no influence. As individuals, we are clearly powerless.
On the other hand, since we remain the guts of the practice of
medicine, if we begin to take responsibility for the healthcare
system and speak with a unified voice, we may no longer be
merely at the effect of what Big Business, Big Insurance, and
Big Media decide the system will be. It’s time to put aside
our petty differences and begin to speak as one.
For an example, it was during the late 1960s that I applied
for a surgical internship. I was fortunate to be accepted at
Columbia but at a yearly salary that approached poverty lev-
els. Every intern, resident and Fellow in an academic program
106
in our country faced the same problem back then, and we had
no say whatsoever in what our salary should be. But a month
or two before my internship was to begin, the house staff at
Boston City Hospital met with their hospital administration
and demanded a raise. Not unexpectedly, they were turned
down flat. Helpless as individuals they decided to bring some
pressure as a group. What evolved was the “Boston City
Heal-In.” No one refused to see patients or failed to show up.
Instead, day after day for about a week, every patient who
came to Boston City’s emergency room was admitted, first to
the floors and then to every hallway in the hospital. The
result was that within a month, house staff salaries tripled not
only throughout Boston but also throughout New York City
and hospitals beyond.
My point should be obvious. If we are dissatisfied with our
circumstances, continuing to whine about the inequities dur-
ing lunch has lead us nowhere. If we are to regain any mea-
sure of control, we need to be organized in our approach and
reset the standards of the entire healthcare industry, standards
that disappeared when the focus changed to economics. We
need to re-develop the importance of intellectual honesty
within our profession and with the patients. We must begin to
respond to the drug companies, the media and the public as a
group, and tell them what the real priorities are in healthcare.
Doctors should be proactively publicizing the issues, even the
unattractive ones, not news anchors. We need to settle on
issues, one at a time, and create a voice that collectively
speaks for the way we know medicine should be practiced.
We also need to be unified followers of that voice. Carping
has not worked, and more of what doesn’t work, doesn’t
work. The answer clearly does not reside with the AMA or
similar organization as they are currently conceived.
Where the hell is Moses when we need him?
9 The Defense Attorney’s Prospective
Steven M. Gonzalez, JD
9.1 Introduction
Medical malpractice actions against physicians usually cause
the physician to suffer tremendous stress and anxiety. Not
only is their financial security threatened, but the profes-
sional competence they have worked so hard to obtain is at
issue. The best way to deal with the threat of a medical mal-
practice lawsuit is to actively participate in your own defense.
Many physicians are so outraged and hurt when they are
served with a malpractice suit that they understandably do
not want to get involved. As the process of the lawsuit con-
tinues, the physician may become increasingly irritated by
the onslaught of requests for material and documents that
must be provided in a timely fashion. There are meetings and
N.R. Reisman et al.
depositions that are scheduled and cancelled, and this can
wreak havoc on the physician’s professional and private
schedule. For all of these reasons, it is easy for the physician
to become disenchanted and take a hands-off attitude toward
the litigation. This is a mistake. The physician must use the
legal system to its fullest to provide the greatest chance of
winning the case and ending the ordeal.
Lawyers do not win or lose medical malpractice cases.
Doctors win their cases and sometimes lose them. To have
the best chance of winning, the physician is required to dedi-
cate hours and hours of time thinking, reading, and meeting
with attorneys to obtain critical legal advice on how to
respond to written questions, answer deposition questions,
and how to present at trial. Also, the physician must educate
the defense attorney in the medical issues of the case. After
years and years of defending medical malpractice cases,
oftentimes, the defense attorney will have a working knowl-
edge of certain aspects of plastic surgery and other medical
aspects such as coagulation, signs and symptoms of infec-
tion, and other basics. However, the physician should not
expect the defense attorney to already have expertise in the
detailed medical issues of each case. Plan on teaching your
attorney the medicine, and allow the attorney to teach you
how to handle each step of the legal process in defending
your case.
9.1.1 The Claim
A claim of medical malpractice is not the same as a medical
malpractice lawsuit. Typically, before there is a lawsuit,
there is a claim. A claim is nothing more than a patient or
that patient’s attorney sending written notification that a
claim is being made or contemplated. Oftentimes, the physi-
cian will receive a certified letter asking for copies of office
records so that the potential claim can be investigated by the
patient’s attorneys. Hospital records are obtained directly
from the hospital, and the physician has no responsibility to
produce hospital records or records outside his or her direct
possession.
At the time a claim letter is received, it should be imme-
diately turned over to the insurance carrier. Most times, the
insurance carrier will consider whether to hire an attorney at
the “claim stage” or wait to see if a lawsuit is filed. There are
varying opinions on whether a defense attorney is needed at
the claim stage before the lawsuit is filed. Sometimes,
although infrequently, claims are settled before a lawsuit is
filed. If an attorney is involved at the claim stage, the defense
and plaintiff attorneys have an opportunity to exchange
information and conceivably negotiate if the claim warrants
settlement. Theoretically, exchange of information at the
claim stage before the lawsuit is filed is intended to resolve
meritorious claims early and also prevent filing of non-
meritorious claims. The physician should never undertake to
have discussions with the patient’s attorney once a claim letter
The American Legal System
is received. Only through the insurance carrier and/or defense
counsel should any discussions take place with the patient’s
attorney. The insurance company will direct the physician
how to respond to a claim letter. Usually, the physician will
simply forward the copies of the office chart to the plaintiff’s
attorney without commentary or discussion. Since the claim
has been turned over to the insurance carrier, the physician
has fulfilled his obligation to timely notify the insurance car-
rier of the claim. Remember, all insurance policies require
prompt notification of claims to the insurance carrier. A fail-
ure to promptly notify the insurance carrier could result in a
waiver of coverage, leaving the physician “bare” or without
coverage. This could result in thousands of dollars in out-of-
pocket expenses to the physician to cover attorney’s fees and
any settlement or judgment that could result.
Many times, the insurance carrier will ask the physician
to prepare a typed narrative of the events giving rise to the
claim. This would usually include a chronological outline of
events beginning with the first patient encounter and ending
with receipt of the claim letter. It is always worthwhile to
prepare a chronology timeline since it will allow the insur-
ance carrier to conduct early evaluation of the claim to deter-
mine if settlement might be indicated. In most jurisdictions,
written communications between the insured physician and
the insurance carrier are privileged and not subject to pro-
duction to the plaintiff’s attorney. Thus, this written outline
will be shared only with the insurance carrier and the attor-
ney hired to defend the physician. However, every state has
different rules of procedure and evidence. Before preparing
written materials, the physician should be certain as to
whether production of the document might be required at a
later date. The last thing you want to do is prepare a docu-
ment that will later be used against you.
From the very beginning, the approach to defense of the
case should be as if the case will go to jury trial and verdict.
Although subject to debate, I do not believe in defending
cases with a goal of out-of-court settlement. Occasionally,
there are situations that require settlement when the medical
care cannot be defended. Thankfully, these situations are
rare. But even in the situation of an indefensible case, it must
be defended aggressively and without signs of weakness or
early surrender. A stern defense of the indefensible case will
still yield better results for the physician than admitting fault
and giving up.
Once the medical records have been sent to the patient’s
attorney, there is typically a waiting period before the lawsuit
may be filed. Some states require a period of abatement
where the lawsuit cannot be filed. This is intended to give the
parties an opportunity to evaluate the claim and carry out
settlement negotiations before the lawsuit is filed. If the
insurance carrier decides the case does not warrant settle-
ment, there may be a long waiting period before the physi-
cian knows whether the claim will become a lawsuit or not.
107
The patient’s attorney will send a written notification to the
physician and the insurance carrier that an election was made
not to file suit and that the attorney was closing his file. This,
of course, does not prohibit the patient from seeking advice
from a different attorney who may take the case. Thus, until
the statute of limitations has expired, there is always a chance
that a lawsuit will be filed. Hopefully, the physician will hear
nothing from anyone until the statute of limitations expires,
at which time the insurance carrier will typically send a letter
to the physician noting that limitations expired and that the
insurance carrier was closing its file. Obviously, this is
always great news to the physician.
9.1.2 The Lawsuit
On a not so happy note, the physician’s next communication
from anyone may be service of suit papers. Typically, a local
constable or process server will serve papers at the physi-
cian’s office or home. Many physicians believe they can
avoid a lawsuit by hiding from process servers. These efforts
include sneaking out of the office and escaping down the
hospital corridors when the server attempts to deliver suit
papers. Recognize that the plaintiff’s attorney will not allow
a lawsuit to go unserved. If the physician avoids receiving
suit papers, the plaintiff’s attorney can ask the trial judge to
order substituted service which only requires posting the suit
papers in the courthouse for publication. If this happens, the
physician will be technically served and not have direct
knowledge of the suit papers. It is not worthwhile or in the
physician’s best interests to run from process servers. You
will get served anyway. Therefore, accepting the suit papers
and getting on with your defense is in your best interests.
Recently, an emergency room physician received suit papers
at the ER. He was busy and laid the suit papers on a desk
where they were lost. Of course, a default judgment for hun-
dreds of thousands of dollars was entered against the ER
physician in a case that was completely defensible had he
responded to the suit papers. Additionally, by failing to
notify his insurance carrier, he waived his coverage and was
left bare. Do not make a mistake similar to this one. As soon
as you receive suit papers, contact your insurance carrier by
telephone and fax the papers directly to the insurance claims
representative. Don’t wait 7–14 days before contacting your
carrier. Remember, your answer may be due in 20 days or
less from your receipt of the suit papers. Give your insurance
carrier as much time as possible to set up your file, hire an
attorney, and give due consideration to any defenses that may
be raised at the time or even before your answer is due.
Soon after sending the suit papers to your insurance car-
rier, you will receive notification identifying your attorney.
Most insurance carriers retain the right to select counsel for
you, but oftentimes the carrier will honor your request for a
specific defense attorney. This usually depends on whether
the insurance carrier has a preexisting relationship with the
108
particular defense attorney. Of course, you are always enti-
tled to hire an attorney of your choosing as “personal coun-
sel.” The role of personal counsel is to look out for your
interests as they could potentially conflict with the insurance
carrier’s. In the great majority of cases, personal counsel is
probably unnecessary. It also can amount to considerable
expense to the physician, since the insurance carrier will not
pay the fees for personal counsel. However, depending on
the peculiar facts of the case and the potential for a large
monetary judgment against the physician, it may be advis-
able that the defendant physician hire personal counsel.
The question often arises as to how much insurance cov-
erage the physician should carry. This issue is touched upon
in other chapters, but even more importantly than the amount
of coverage, the physician should carefully consider the
financial stability and track record of the insurance carrier.
Recently, on a nationwide basis, numerous insurance carriers
have left the market or gone into some form of receivership
or bankruptcy. In these situations, physicians are left bare
without coverage. Buying insurance from a longstanding,
solvent and secure insurance carrier is very important. It is
usually worth paying added premium to obtain coverage that
you know will be there if you receive a claim or lawsuit. The
amount of coverage you need will depend on the peculiari-
ties of your practice, likelihood of receiving a claim, and
your financial situation. Many physicians believe that carry-
ing a minimal amount of insurance is preferable since a phy-
sician with less insurance is a less attractive target. There is
no single, correct answer to this question and each physician
must make a personal decision with advice of counsel.
As soon as you can, contact the attorney assigned as your
defense attorney. The best thing you, as a defendant, can do
is to immediately develop good rapport with your attorney so
you can work together as a team, complementing each other.
The attorney-client relationship is much like the physician-
patient relationship. All physicians have had demanding
patients. Physicians do not look forward to seeing these
patients or being subjected to their demands. Attorneys like-
wise do not appreciate being ordered around by their physi-
cian clients. Try not to vent your anger toward the plaintiff’s
counsel against your own attorney simply because they are
both lawyers. The defense attorney usually does nothing but
defend physicians and shares some amount of philosophical
disdain for the plaintiff’s claims.
You also must recognize that your attorney’s time is just
as valuable as your own. Each of you is an expert in your
own area, and you should work together toward resolving the
suit. It is important to visit your attorney at his or her office.
Just as you are limited in your ability to provide total care
without all your tools at your disposal, an attorney is limited
outside his office. All of the details of your case, the lawyer’s
support staff, and appropriate law references are available in
his or her office. It soon becomes clear that your meetings
N.R. Reisman et al.
will be more fruitful there, unless the attorney asks to visit in
your office. At some point, your defense lawyer will proba-
bly need to see your office, the examining rooms, and possi-
bly visit with your staff. You should make all of this available
to the attorney on request.
At the time of your initial meeting, your attorney will ask
you to describe all details of your involvement with the
patient and the care that was provided. Do not withhold any
important information from your attorney. All communica-
tions with your attorney are privileged. Pursuant to law, you
will never be required to disclose the content of discussions
with your own attorney. Likewise, your attorney is legally
and ethically prohibited from sharing the content of those
conversations with anyone. The question arises as to whether
previous lawsuits against the physician or other past blem-
ishes are subject to disclosure to the plaintiff’s attorney.
There are two issues at hand. First, whether something is dis-
coverable and second, whether something is admissible.
Discoverability concerns whether the plaintiff’s attorney
may ask questions and receive answers in any given subject
area. Something may be discoverable but not admissible. For
example, if a physician has had past medical malpractice
actions and/or settlements, the plaintiff’s attorney may be
entitled to discover that information by asking questions at a
deposition or in written interrogatory questions. However, in
the majority of cases, past lawsuit information against the
physician is not admissible before the jury. Likewise, a phy-
sician could potentially have had past criminal charges or
alcohol/chemical dependency problems. The physician may
also have had staff privileges limited or suspended. If han-
dled correctly and up front, the defense attorney can poten-
tially protect these areas from discovery and certainly from
admissibility in front of the jury at trial. However, if the phy-
sician withholds information from the defense attorney, the
chances of protecting it from discovery and admissibility are
weakened. Your attorney can best protect you if all informa-
tion is disclosed. Certainly, each and every strength and
weakness of the medical case should be disclosed by the
physician to the defense attorney.
Before performing medical research and pulling studies
and articles, the physician should first obtain permission
from the defense attorney. Conceivably, the fruits of your
research might be required for production to opposing coun-
sel. It could be that you do not want to turn over medical lit-
erature and articles to the plaintiff’s attorney at all, and
certainly not early in the lawsuit. Some medical malpractice
cases rely heavily on studies and medical literature while
others are tried to jury verdict without a single reference
being introduced. In all instances, ask your attorney for
advice on what to read, and when to read or pull medical
literature. In that same vein, ask your attorney before dis-
cussing the case with other physicians, office staff, or poten-
tial “experts” that you may be aware of. Once again, you may
The American Legal System
not want the results of your work and conversations to
become discoverable or admissible at trial, and only with
your attorney’s guidance can you succeed in this goal. Of
course, your attorney may ask you to perform research and
pull supportive medical literature. If so, do so. You have a
much better grasp of the pertinent research, studies, and
medical literature than your attorney, and you can go a long
way to winning your case by helping in this area.
9.2 The Deposition
From the first meeting with your attorney, you will begin
working toward the goal of achieving the best result possible
during your deposition. After the initial exchange of written
information between the parties, the deposition is the single
most important event during the discovery phase leading to
trial. Its importance should not be underestimated. Cases
cannot be won at deposition, but cases are lost at deposition.
From the defense perspective, the only reason the defendant
doctor gives a deposition is because it is required by our
rules of procedure. Of course, the plaintiffs are also required
to give their depositions, so the system is fair and not one-
sided. However, only bad things can happen at the defendant
doctor’s deposition. The only good thing that can happen is
to survive the deposition completely intact without self-
incriminating testimony in the record.
Your attorney will advise you on what you should do
between the time of your initial meeting and your upcoming
deposition, which may not occur for 6 months or longer. You
may or may not be asked to review records from the hospital
and other treating physicians. As stated, you may or may not
be asked to perform medical research and/or have discus-
sions with others about your case. At the initial meeting, ask
your attorney for advice on exactly what you should or
should not do leading up to the time of your deposition.
During the initial meeting, you should be prepared to
identify strengths and weaknesses in your care. There is no
case ever reviewed that is completely free of weaknesses.
Oftentimes, there is poor charting in the office or hospital
record. All realistic physicians recognize that they could
chart better, especially in hindsight. Identification of these
weaknesses, as well as the strengths, is critical to your
defense. A list of strengths and weaknesses should be drafted
and continually updated as the case proceeds. Oftentimes,
you may have a very distinct understanding of the direction
being taken against you by the plaintiff’s attorney. Recognize
that their direction may change as the case develops. The
case may begin as an informed consent case but in the end
turn on some completely unrelated aspect of care. Don’t be
deceived. All aspects of your care should undergo self-
scrutiny and be shared with your attorney so you will not be
caught by surprise if the direction changes.
109
The order of depositions is usually the same. In most
jurisdictions, the defendants have a right to question the
plaintiffs first. Once the plaintiffs’ depositions are com-
pleted, then the defendant doctors and/or hospital employees
will give their depositions. After these are completed, typi-
cally the plaintiffs’ expert witness(es) are presented for
deposition, to be followed by the defense expert witness(es).
Intermingled in these depositions are a variety of fact wit-
nesses that may range from office staff to employers and pos-
sibly friends or family of the plaintiffs. In most cases, it is
advised that the physician attend the plaintiff’s deposition,
particularly the patient. Attending depositions assists the
physician in a couple of ways. First, it gives the physician an
opportunity to observe all of the attorneys involved in the
case and become more accustomed to their personalities and
tactics. Second, the physician hears the testimony firsthand,
and can assist the defense attorney with follow-up questions
or important areas that the attorney might not recognize
without physician input. Some physicians have been known
to fly cross-country to attend depositions of the plaintiffs’
expert witnesses. While this may seem to be overkill, in
some cases that extent of participation can be extremely
helpful and potentially make a difference in outcome. Once
again, consult with your own attorney, but have an open
mind about dedicating your time to defending yourself. The
more you participate, the better the result. In regards to
scheduling, unfortunately, meetings, depositions, and trial
are constantly scheduled, cancelled and rescheduled. Make
sure to explain this to your staff and people doing your
schedule. This is not due to a lack of respect toward the
defendant physician. It is the result of the way the legal sys-
tem is set up and practiced. Most busy plaintiffs and defense
attorneys have trial settings every week, which are subject to
being called on a day’s notice. This requires cancellation of
meetings and depositions. Although it is inconvenient and a
disruption, the physician must understand and accept that
this is usually beyond anyone’s control. Keep in close con-
tact with your attorney through his staff regarding scheduling
and deadlines. By doing so, you have a better chance of
being ahead of the game when it comes to cancellations and
rescheduling.
You should create a system to store correspondence and
other documents exchanged between you, your insurance
carrier, and your attorney. These materials should not be kept
in the patient’s office chart. Do not leave these materials
lying around in the office where they might be misplaced.
Also, these materials are sensitive and should not fall into the
wrong hands. Keep these documents in a secure file cabinet
either at home or in the office. Also, the original office chart
should be secured so it cannot be lost, destroyed, or altered.
When you meet with your attorney, be sure to bring with you
all materials pertaining to the case, including the original
chart and any studies that may exist. If you need a copy of the
110
hospital chart, ask your attorney how to obtain one. Most
physicians with hospital privileges can obtain a copy of the
hospital record. If you do, make sure and obtain your copy
via proper channels, typically by asking hospital risk man-
agement or administration to provide a copy to you. If you
are in possession of the original hospital record some time
after the threat of a claim or lawsuit, it could be implied that
you altered the hospital chart to cover yourself. You do not
want there to be any question about your access to the origi-
nal hospital record, alteration, destruction of hospital records,
or spoliation. Remember, anyone could have a copy of the
original hospital or office record. Assume that any changes
made after the fact will be discovered by opposing counsel
and used against you. One thing juries disdain is a cover-up
or lie. Even defensible cases can be lost if the jury believes
the physician participated in a cover-up.
9.2.1 Deposition Topics
There are topics covered at virtually every deposition.
Covering these areas with your attorney during pre-
deposition preparation will yield a better result. Some of
these areas include the following:
• Standard of Care: Standard of care is a term created by
lawyers and judges, and adopted by medical practitioners.
It is ill-defined, but is synonymous with many phrases
oftentimes used during the deposition. These include
“good medical care,” “reasonable medical care,” “prudent
care,” “standard care,” “expected care,” etc. The list of
substitute phrases for standard of care is a long one, but
suffice it to say that standard of care is simply whether the
physician acted reasonably.
• This does not mean that every single physician must agree
or disagree with what was done. There is considerable
room for honest disagreement as to the approach taken by
any physician in most circumstances. There may be
numerous approaches to the care of a patient ranging
from doing nothing to performing major surgery. Many of
these approaches may fit well within the standard, reason-
able, prudent, expected care, and thus not represent negli-
gent care. Plaintiffs and their attorneys would like there to
be a single course of care to the exclusion of all others. In
thinking about the case and your deposition testimony, it
should be remembered that there may be a variety of
approaches that are reasonable, including your own.
• Causation: Every malpractice case requires three ele-
ments, which include a violation of the standard of care, a
causal link between the violation and injury, and the exis-
tence of damages to the plaintiff(s).
• Informed Consent: Especially in the area of plastic sur-
gery, the patient has a considerable role in self-determining
the type of care rendered and whether to proceed with
surgery in light of many risk factors, including death. In
N.R. Reisman et al.
almost every plastic surgical case, informed consent is at
issue. As a plastic surgeon, you should become intimately
familiar with the exact law of informed consent applica-
ble in your specific state. You would be advised to consult
an attorney to assist in preparing written consent forms
that will afford you the best protection based on your
state’s informed consent laws. Remember, it is incumbent
on the physician to obtain informed consent, not the
nurses or hospital staff. You and your office staff should
insist on verifying accurate signatures, dates, and times
on forms where the patient acknowledges understanding
the significant risks and potential benefits, as well as alter-
native treatment options attached to the proposed surgery.
It is the patient that requests surgery. The surgeon does
not dictate treatment or surgical choices to the patient.
• Authoritative Literature: In many jurisdictions, the judge
will determine admissibility of medical literature based on
whether a competent expert identifies the literature as
“authoritative.” Like the phrase, “standard of care,” author-
itative literature is a creature of law, not medicine. Bottom
line, if you want to use a particular article, you or some
competent expert must identify it as authoritative. You
probably subscribe to one or more journals. While you may
read the New England Journal of Medicine, you certainly
would not agree with every statement of every article ever
published in that journal. Usually, the defendant physician
could comment on whether he agrees or disagrees with the
conclusions of a particular medical article, but not that an
entire body of literature as a whole, is “authoritative.” No
journal as a whole can be called authoritative or reliable.
Rather, statements or conclusions in specific articles may
be authoritative. Thus, if asked whether you agree or dis-
agree with an article, you as the witness should be entitled
to review the article, the conclusions therein and its refer-
ences before offering an answer. It may be that you could
not complete your analysis if presented with a specific
article at your deposition. You may not want to produce
articles at your deposition, and you should consult your
attorney to formulate a strategy for avoiding production of
defense articles until the appropriate time.
• Expert Witness: What is the definition of an expert wit-
ness? Each state will have laws that govern this question.
Commonly, expert witnesses are required to practice in
the same area of specialty as the defendant physician and/
or have particular experience, which would qualify the
individual to offer standard of care testimony.
– You are your own best expert. Unlike the plaintiffs’
expert, you actually examined and treated the plaintiff.
You have the built-in advantage of being able to recall
conversations in the office, at the hospital, as well as the
appearance of structures during surgery, and wounds
post-operatively. No “hired expert” can have that unique
perspective, and you should exploit your advantage.
The American Legal System
– If you know of potential experts to assist in defense of
your case, provide their name and location to your
attorney, but do not contact the expert yourself. Ideally,
the defense would like to maintain a separation
between the defendant doctor and the defense experts.
Allow your attorney to contact the experts and retain
them as needed.
• Other Caregivers: A simple, yet very effective strategy is
to use the defendant physician’s testimony against other
defendant caregivers. During the deposition, the plain-
tiff’s attorney is permitted to ask any qualified witness
whether the care provided by other physicians, nurses, or
technicians was within the standard of care. One defen-
dant physician is oftentimes pitted against another defen-
dant physician or the hospital.
– If one physician “dumps” on another physician or the
nurses, human nature would dictate that the others
fight back. As you can imagine, if the defendant physi-
cians and nurses are all blaming each other during their
depositions, the case will be lost by everyone. There
are fact patterns where one of numerous defendant
physicians is almost entirely culpable for the outcome.
A typical example would involve a failure to correctly
diagnose where all caregivers relied on an erroneous
x-ray or pathological slide interpretation. It is best in
that scenario for the culpable defendant to accept
responsibility and not try to create liability against the
other defendant doctors or nurses. In other words, if
it’s your turn, you should step up to the plate and fight
for yourself, not blame others. Where the defendant
doctors and nurses all have laid defenses, then every-
one should fight together for each other. A unified
defense among caregivers is the strongest weapon in a
multiparty case. There is nothing the plaintiff’s attor-
ney likes more than to have the defendant caregivers
dumping on each other.
– Therefore, you and your attorney should cover how to
handle questions that might cause problems to your
codefendant physicians, nurses, and even other care-
givers that are not yet defendants in the case. If the
statute of limitations has not expired, you could
unknowingly make a case against an unnamed care-
giver and become the star witness for the plaintiff
against that caregiver. Give due consideration to how
you will handle the question of whether the other phy-
sicians and nurses acted appropriately and within the
standard of care. Be prepared to defend the other care-
givers if asked.
• Charting: There is no greater myth than the statement, “If
it’s not charted it wasn’t done.” Despite this reality, doc-
tors and nurses offer deposition testimony that this is a
valid statement. Physicians do not chart every aspect of
their thought process and each and every possible diagno-
111
sis that entered their mind during their care of the patient.
Additionally, caregivers do not write down every single
conversation they had with the patient, consultants, or
nurses. They similarly do not chart each and every inter-
vention or negative findings. The office chart has a differ-
ent purpose than the hospital chart, and the distinction
must be kept in mind at deposition. The office chart is
used by that particular practitioner, his staff, and possibly
other physicians practicing within the group. The office
chart has a more limited purpose and is commonly more
concise and abbreviated. The hospital chart is used by a
greater number of caregivers, and typically is a regi-
mented protocol of entries starting with the admission
H&P, physician orders, nurse’s notes, consultant notes,
operative reports, etc. Closely examine the hospital chart
and note the titles attached to each section of the chart.
The fine print will tell you that the hospital chart is also
not meant to contain every single conversation between
physicians and nurses. Likewise, it is not intended to con-
tain every single thought a surgeon has about the patient
or every aspect of that day’s examination.
– Do not agree with the plaintiff’s attorney that each
and every significant thought, conversation, or inter-
vention must be documented or it was not done. Of
course, the plaintiff’s attorney would like for this to be
the case. On the other hand, if a patient did not receive
care and dies because the physicians and nurses were
busy charting, he would be first in line to file suit for
prioritizing charting over patient care. Remember,
patient care is more important than charting. Each
physician charts differently and there is no universal
standard for how much should be written in an office
or hospital chart. You are not bound by only what is
noted in the chart. There always are evaluations,
thoughts, and conversations that are not recorded in
the medical record.
• Advertising and Warranty: Before giving your deposition,
discuss any advertising you have done with your attorney.
Unique to plastic surgery is the possibility that the law
could convert representations you have made as to result
into a contract to cure or breach of warranty claim. The
burden of proof for breach of contract or breach of war-
ranty is significantly lower than a negligence claim. In
fact, if through your advertising or representations, you
have promised a particular result, the mere failure to
achieve that result would give rise to damages irrespective
of negligent care. Thus, make sure that your advertising in
whatever media does not promise a particular result. Be
careful not to give your patient’s photographs or computer
animations of exactly how they will look after their cos-
metic surgery. Also, make sure your patient signs an
acknowledgment that there is no warranty, promise, or
guaranty as to the result.
112
• Hypothetical Patient: Favorite questions surround how
the physician should treat a particular hypothetical
patient. Clearly, the rules of procedure and evidence per-
mit the use of hypothetical questions during depositions
and at trial. These questions of how you should or should
not treat a hypothetical patient are a set-up for disaster.
Typically, the plaintiff’s attorney will ask the defendant
physician how to treat a hypothetical patient (not the
plaintiff) if the patient presents with a certain clinical con-
dition, such as a wound with specific signs and symptoms
of infection. The unknowing defendant physician will
agree that in the case of the given hypothetical, that the
patient should immediately be hospitalized and started on
intravenous antibiotics. Then it comes down to a battle of
who do you believe, because from that point forward, the
plaintiff’s clinical condition will mirror the hypothetical
patient diagrammed by the plaintiff’s attorney.
– In order to avoid this trap, it is simple enough to tell the
plaintiff’s attorney that you cannot treat hypothetical
patients. That in order to make a treatment decision as
to hospitalization or initiating intravenous antibiotics,
patient history, pertinent physical examination, and
evaluation is necessary. It is usually safe to explain that
physicians treat real patients, not hypothetical patients.
– There is no simple ten-step cookbook to follow in giv-
ing a deposition. Most physicians enter the deposition
believing that the case will be dropped if they can only
convince the plaintiff’s attorney that their care was
appropriate. Nothing is further from the truth. By tell-
ing the plaintiff’s attorney why you should not be a
defendant in the case, you will cause harm to your case
and provide a road map on where to attack the defen-
dant doctor at trial. All defendants, not just physicians,
are naturally defensive. It is better to simply give short,
concise answers and not enter the deposition for the
purpose of defending yourself. Obviously, you must be
there to defend your actions. However, unless forced,
do not outline all the good reasons why the case against
you is frivolous. Let the plaintiff’s attorney find out for
the first time at trial when it really counts.
– Most physicians dress professionally when they appear
for a deposition. I recommend that the defendant phy-
sician wear a jacket and tie, since most depositions are
videotaped and may be shown to the jury at trial. If you
are not the defendant but merely a treating physician,
then scrubs and a lab coat will suffice.
– The above pointers are some of the areas that are
always covered and sometimes cause the most difficul-
ties for defendant doctors. Spend as much time as pos-
sible with your defense attorney to prepare for the
deposition. Ask the attorney to walk you through a
curtailed version of what might be a longer deposition,
and practice the five or ten questions that would be
N.R. Reisman et al.
most difficult to handle. These are usually on the list of
possible weaknesses in the patient care that you and
your attorney have already identified.
9.2.2 Post-deposition
Once you have completed your deposition, each side will
present expert witnesses for deposition questioning. You may
have access to information about the opposing expert wit-
nesses, which you should make available to your attorney.
This would include any literature written or published by the
opposing expert as well as that expert’s education, training,
experience, and practice pattern. Many times, the defendant
physician can obtain useful information about the plaintiff’s
experts from colleagues in other cities and information
available through societies. Your attorney should make the
written reports of the plaintiff’s experts available to you for
your evaluation. Prepare an outline of the strengths or weak-
nesses in the plaintiff’s expert opinions as contained in reports
turned over for that expert’s deposition. If there are particu-
larly weak areas, your attorney may explore them at the
expert’s deposition or save that for trial. Be understanding if
your attorney chooses to reserve areas of attack for trial, since
there is a lot of strategy that comes into play in deciding when
to attack or when not to attack any particular witness.
By now you should have a collection of deposition tran-
scripts. The next major step in the lawsuit will probably be
court-ordered mediation. Most jurisdictions now require that
all parties attend mediation before trial. Mediation is typi-
cally a half day or a full-day process, but can sometimes last
longer than one day. Mediation can sometimes be worth-
while. It is the only opportunity that the physician and
defense attorney will have to confront the plaintiff and fam-
ily members face to face. At mediation, defendant doctors, a
hospital representative, the plaintiff, and all attorneys sit
down at a table with a trained mediator for the purpose of
resolving the lawsuit before trial. The terms of resolution
may range from dismissal of the lawsuit all the way to pay-
ment of large sums, up to and beyond the insurance policy
limits of the defendants. Most mediations are nonbinding; in
other words, you are required to attend and participate, but
not required to pay money or settle. At the opening joint ses-
sion, each attorney will make a verbal presentation on behalf
of their respective clients. The defendant physician is not
required to speak, but there are occasions where it might be
helpful to have the physician speak directly with his former
patient, now plaintiff. This is something the defense attorney
will advise for or against. The content of the proceedings at
mediation, and any settlement offers made, and the outcome
of mediation, is privileged and confidential. Statements made
or positions taken at mediation are not admissible at trial. In
fact, the jury will never be told that a mediation took place or
whether any settlement discussions occurred before trial.
The American Legal System
9.2.3 Trial
If you have worked hard and followed your attorney’s advice
leading up to trial, you should be in a position to defend
yourself in front of a jury. However, your performance at
trial will be the single most important factor in determining
the outcome. By the time you go to trial, you should be well
familiar with your deposition testimony. The transcript can
be read to the jury and used during cross-examination while
you are on the witness stand. The defendant physician must
read and reread the deposition transcript to be aware of pos-
sible weaknesses in testimony. Many times, well-prepared
defendant physicians can recite the four or five pages where
borderline questions are answered, and have explanations for
why the answer was given and what was meant. Also, the
defendant physician should carefully study the testimony of
his own experts. The deposition testimony of other witnesses
can be used to cross-examine the defendant physician. Only
if you are familiar with your own expert’s testimony can you
defend his positions as well as your own. In short, by the
time trial begins, the defendant physician should read and in
a sense commit to memory his own testimony, the testimony
of the expert witnesses, especially defense experts, and the
key testimony given by fact witnesses. As well, the defen-
dant physician must commit to memory the key entries in the
medical record, which will make a difference in the outcome.
Many times, there are places in the chart that either contain
or are absent of key entries for the defense. These must be
committed to memory. Additionally, if there are important
medical articles, the physician should understand them and
be able to explain the studies or article conclusions to the
jury in lay terms. This may take practice before trial.
At trial, credibility is paramount. The jury will weigh the
credibility of the witnesses; that is, their believability. In
weighing the credibility of the defendant physician, the jury
will consider a physician’s demeanor. There is no need to
dress, look, or act like a lawyer just because you are in court.
In fact, a defendant physician must behave like a physician.
Someone who is caring, humanistic, but also a scientist. A
defendant physician must be accurate and precise in thought
and speech. The defendant physician should have a neat,
clean attire, but does not have to wear a brand new suit each
and every day. Modest, alternating blue blazer, slacks, shined
shoes and an occasional suit is just right. Sitting up straight,
113
occasionally making notes and occasionally whispering to
defense counsel is the right look. The defendant physician
should show confidence by looking directly at the jurors and
not shying away. He should never speak with the plaintiff or
plaintiff’s counsel anywhere near the courthouse and should
not be laughing or joking in the hallway with anyone. The
case should not be discussed in the hallways or elevators, or
even in the courthouse parking lot. Jurors have a funny way
of suddenly appearing out of nowhere and listening in on
discussions between anyone in the area. Be careful how you
act and what you say at all times. Assume you are always
under the watchful eye of one or more jurors, because you
probably are.
Be absolutely respectful to everyone in the courtroom,
including the judge, the jury, the courtroom bailiff, and even
opposing counsel. Answer question with firm, committed
“yes sir’s” and “no sir’s.” Do not argue with the judge. If the
judge gives you any instruction, answer very respectfully,
“Yes, Your Honor” and do your best to follow whatever
instruction you are given. Never panic or look scared. If the
plaintiff’s expert is hurting you, just sit up straight and take
it. You and your experts will have a chance to rebut that tes-
timony, and you must be patient. Remember, the plaintiff has
the burden of proof. Therefore, the plaintiff puts on their case
first. The lowest point for the defense in any case is almost
always the middle or end of the plaintiff’s case. This is natu-
ral since many times, the defense has not had a good oppor-
tunity to put on their case and their defenses. Once again, be
patient and hang in there. You may think the case has been
lost, only days later to realize that everything is going your
way and that you probably will win.
After you have won at trial, you will have an opportunity
to thank the jurors for their public service. Most physicians
are overwhelmed with joy and a sense that they have been
exonerated. Learn lessons from this ordeal. Improve the
areas of your practice so that you can defend yourself better
in the future. Whether it be big or little things, every physi-
cian, not to the exclusion of every lawyer, can improve
aspects in the manner of their practice. It may have to do
with intake of new patients at the office or a different way of
charting at the hospital. Whatever it is, take the positive les-
sons you learned from this lawsuit and do everything you can
to avoid what you have just gone through.
 Part II
The Breast
 History of Aesthetic Breast Surgery
Thomas M. Biggs
History does not record when the first breast surgery was
performed, but common logic suggests the operation was drain-
age of a breast abscess, probably using a sharp piece of bone. It
only follows that some inventive, creative thinker would later
use some sharp object to excise a necrotic bit of tissue.
As history moved into the Bronze Age (3200 B.C.) and
then into the Iron Age (1300 B.C.), one can reasonably spec-
ulate that more sophisticated instrumentation evolved and
therefore operative ventures expanded. One can also reason-
ably speculate that due to the recognition of the female breast
as emblematic of her gender, some emphasis could have
been placed on its enhancement surgically. But alas, progress
in this area needed to wait until other significant steps in the
evolution of surgery could be made, these being antisepsis
and anesthesia. Thus, like all other aspects of surgery, great
progress had to wait until the nineteenth century.
The nineteenth century brought to the aesthetic aspects of
breast surgery crude efforts at resection of redundant skin
and parenchyma and a repair of the wounds in as unobtrusive
way as possible, with suture materials being crude and primi-
tive, and the procedure being a race with the clock due to
anesthesia limitations. Wound necrosis and necrosis of the
nipple-areola complex were not an uncommon problem. The
evolutionary process had to wait until the middle of the
twentieth century before full understanding of the blood sup-
ply to the breast was routinely employed by operative sur-
geon in flap design.
1 Breast Reduction and Mastopexy
This author was fortunate to come into plastic surgery at a
time when great leaps forward were beginning to occur. The
extensive skin undermining and parenchymal and skin resection
T.M. Biggs, MD
Private Practice, Houston, TX, USA
e-mail: tbiggs@aol.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_10
of Biesenberger [2] gave way in 1956 when Robert Wise
[17] introduced a pattern for skin excision that was easily
understood and easy to carry out. A problem with this
maneuver was that the nipple-areola complex could be
moved only a short distance and the shape of the breast was
determined by the angle of vertical skin excision (or, skin
tightening determined the shape).
Using the Wise pattern in larger reductions left the nipple-
areola complex (N-A complex) vulnerable to devasculariza-
tion, thus necessitating the frequent use of a free nipple graft
which, in many individuals, was highly unsatisfactory from
an aesthetic point of view.
In 1960, the world welcomed a new way to maintain
blood supply to the N-A complex when it was being moved
a significant distance via the transverse bi-pedicle flap of
Strombeck [16]. The incorporation of this dermal-glandular
flap in conjunction with the Wise pattern significantly and
consistently improved results in breast reduction as well as
in pronounced breast ptosis correction.
A major problem with the Strombeck flap was the occa-
sional difficulty in folding it into place, which led plastic sur-
geons to another door opened by Paul McKissock, the
bi-pedicle vertical flap [13]. The evolutionary process did
not stop here as plastic surgeons began questioning the effec-
tiveness of the superior component of this bi-pedicle flap,
and began omitting this element. This led them to the next
door, the work of Goldwyn and Courtiss using an inferior
pedicle flap to carry the N-A complex [4]. All these proce-
dures employed the Wise pattern, and all were designed with
preservation of the nipple-areola complex being foremost in
the surgeons’ minds. The shape was determined by the angle
of the vertical limbs at the six o’clock position on the areola.
The width of the base of the breast remained broad, and due
to the fact that the middle third of the lower pole of paren-
chyma was the sole means of supporting the N-A complex,
the phenomenon of “bottoming out” was a frequent problem.
This unfortunate sequela was often interpreted as a “rising
nipple” whereas, in truth, it was a descending of the paren-
chymal flap supporting the N-A complex due to gravity.
117
118
Multiple methods of supporting the flap at a higher level
were (and are still) tried, but none seems to be able to with-
stand nature’s gravitational pull.
A great leap forward occurred in 1970 when Claude
Lassus reported having performed since 1964 a simple verti-
cal excision of skin, a medially based dermal-glandular flap
sustaining the N-A complex [10], and an excision of appro-
priate parenchyma in the midline. This was similar to the
work of Pitanguy, who labeled it a “keel resection,” but his
operation had employed the Wise pattern. In larger reduc-
tions with more skin excision, Lassus would not hesitate to
carry the excision below the inframammary fold, and his
long-term results gave justification to this step by the pro-
gressive minimization of the scar over time.
In 1977, Daniel Marchac began employing a similar
maneuver but did not hesitate when necessary to excise the
redundant skin with a short ellipse at the inframammary
fold [12]. The scar resulting from this excision was signifi-
cantly less obtrusive than that with the procedure employing
the Wise pattern [11]. Madeleine Lejour popularized these
concepts and added the concept of liposuction to the equation
for better shape. Elizabeth Hall-Findlay felt that in most cases
a medially based flap could be more easily rotated into the
appropriate position [7]. She described this technique and
presented it at conferences so clearly that, as of this writing, it
seems to be among the most popular methods in use today.
Another great leap forward came with the introduction of
the skin excision being carried out in a circumareolar fashion.
This was not a new thing, but experiences had been unsatis-
factory until the work of Benelli was presented in 1990 [1].
Benelli excised the necessary skin, resected appropriate
parenchyma, closed the parenchymal defect in various ways
depending upon the situation, and then closed the periareolar
defect with a purse-string type closure, bringing the skin to
the edges of the areola. This maneuver abrogated the problem
of the past which was a severe stretching of the areola due to
the pull of the surrounding skin. Sampaio Góes followed soon
after with the use of an internal mesh to permanently shape
the glandular tissue [15]. From examination of the periareolar
scar, the techniques might seem similar, but the management
of the parenchyma, the actual shaping of the breast, was
totally different. The use of these techniques was initially in
dispute for two reasons. First, the closure of the periareolar
wound required a high level of skill to achieve the results
shown by its initiators, and, secondly, if too much skin was
excised, the closure would create a flat breast.
Recognizing this problem, Moturra and others began
using a “circumvertical” approach to large skin excisions. A
leading proponent of this maneuver was Dennis Hammond
with his SPARE (short-scar periareolar inferior pedicle
reduction mammoplasty).
As the evolutionary process moved along, it was noted
by Graf and Biggs that many otherwise excellent results
had a deficiency of parenchyma in the upper pole [6].
T.M. Biggs
Others had addressed this problem by suturing tissue to the
pectoralis fascia, but gravity always won out over sutures.
These authors presented the same circumvertical skin exci-
sion and appropriate parenchymal excision but created a
chest wall based flap divided on all sides and based on the
fifth and sixth intercostal perforators that was freely mov-
able. It was passed under a loop of pectoral muscle and
rotated cephalad into the upper pole creating what appeared
to be an autoaugmentation with a significantly narrower
breast base. This was an offspring of work done by Pitanguy,
Ribiero, and Daniel.
Progress continues. It must be mentioned that Hester
revived the Biesenberger technique (1985) with his central
mound approach to N-A complex vascularization but neces-
sitates an individual approach to parenchymal shaping and
skin excision.
Also needing mention is liposuction. In some cases of
good shape and modest hypertrophy liposuction alone is sat-
isfactory, as it is in patients with larger breasts in whom aes-
thetics is professed to be of no consequence, but liposuction
as an adjunct to all the procedures has become part of most
surgeons’ armamentarium [5, 8].
Also needing mention is that the surgeon’s skill is more
important than the technique. All the various operative
approaches mentioned above are like keys, and a complete
surgeon has many keys because “no key fits every lock.”
2 Augmentation Mammoplasty
While the techniques described above represent the evolu-
tion of aesthetic surgery of the breast, they never add vol-
ume. The successful addition of volume (augmentation)
followed a different path of evolution. While the requirement
of acceptable anesthesia and recognition of the importance
of antisepsis followed the reduction/mastopexy techniques,
the missing ingredient in progress was the implant itself.
For many years surgeons attempted to augment the breast.
Various products were used including paraffin, stainless
steel, lipomatous tissue, and a variety of synthetic chemical
products. All were failures. Either there was complete
resorption, inflammatory expulsion, or unacceptable harden-
ing. It was not until 1963 that a product could be created that
generated minimal body reaction and could be manufactured
in a wide range of densities (liquid to gel to solid) depending
upon otherwise inconsequential alterations in its molecule.
In 1961, Thomas Cronin attended a meeting of the
American Society of Plastic and Reconstructive Surgeons in
New Orleans, Louisiana. At that meeting he encountered a
former resident who had moved to and was practicing in
Midland, Michigan. During their visit together the former
resident mentioned a company in his city, Dow Corning, had
a product with all the components necessary for a breast
implant. Upon returning to his hometown (Houston, Texas)
History of Aesthetic Breast Surgery
Cronin was apprised by one of his residents (Frank Gerow)
of the fact that intravenous fluids were being put into plastic
bags rather than reusable glass bottles. This reminded Cronin
of the conversation he had had in New Orleans and Cronin
contacted the company Dow Corning and inquired as to their
interest in producing a prosthetic device to be used for breast
augmentation. They accepted the challenge and Cronin and
Gerow went about the task of designing the first silicone gel
breast implant. After a modest amount of research the first
breast augmentation using a silicone implant was performed
in February, 1962, in Houston, Texas, by Cronin and Gerow
and reported at the quadrennial meeting of the International
Society of Plastic and Reconstructive Surgery (now IPRAS)
in Washington, D.C.
The first implant had a thick shell, a thick gel, and a Dacron
backing (to enhance attachment to the chest wall). The first
implants came from the factory unsterilized, necessitating
their being either washed or sterilized in an autoclave.
Acceptance of the implants by both surgeons and patients
was immediate and substantial, but numerous problems were
extant. Since sterilization was random, infections were not
uncommon. Anesthesia was either local or general but ade-
quate sedation during local anesthesia was suboptimal while
general anesthesia, at that time, employed explosive gasses
rendering an electrocautery invalid, thus the necessity of
clamp and tie hemostasis being required. With this type tech-
nique and absence of knowledge of the anticoagulant effects
of aspirin and many other commonly used pain relievers,
postoperative hematomas were not uncommon.
With the advance of surgical knowledge these problems
were minimized, but one significant problem remained, the
development of a fibrous capsule around the implant and its
contracture rendering the implant undesirably firm.
At first it was felt that the Dacron backing was the major
contributor to the contracture, so the manufacturer changed
the large Dacron back to several small Dancon patches, then
finally total removal. This author, in an effort to better under-
stand the problem, did a study with electron microscopy and
discovered some interesting items in the capsule. Several
items were found in the capsule that were felt to be causative
factors in the development of a contracting fibrous capsule.
The first of these was droplets of silicone, prompting us to
push for a low bleed shell. Next were elements of blood
prompting us to push for a hemostatic operative procedure.
We later discovered the problem from the blood was the iron
(Fe) in the hemoglobin which was a nutrient for bacteria.
Other items found were cotton and elements of paper, the
former encouraging us to put no gauze sponges into the
wound and the latter alerted us to the sequelae of our placing
the implants onto the paper drapes.
Despite these improvements we continued to experience
fibrous capsule contractures, and in their zeal to diminish this
problem manufacturers began making a thinner shell and thin-
ner gel implant, which was the beginning of a big problem.
119
The newer (generation two) implants with thinner shell and
thinner gel were found to have suboptimal integrity and car-
ried a high rupture rate, or, better said, a high rate of loss of
capsule integrity, releasing the low cohesive gel into the soft
tissues. At the same time some non-plastic surgery clinicians
were claiming the implants were causing a variety of autoim-
mune diseases, and it was suggested they had carcinogenic
qualities. Investigations into the research and development of
the implants revealed serious deficiencies, and in 1992 the sili-
cone gel implants were prohibited for use in the USA with
most nations around the world following suit. Left out of the
moratorium were silicone implants filled with saline.
Saline filled implants lacked the natural feel of gels and
had a 1–5 % deflation rate each year, but still they were pop-
ular. Interestingly, the gels were still allowed in cases of
reconstruction.
Prior to the moratorium, silicone implants wrapped in a
coat of polyurethane came on the scene, and in numerous
clinicians’ experiences fibrous capsule contracture was mini-
mal. This product was removed from the market because of
questionably significant reports of cancer of the liver in rats,
although there was never a reported case of cancer of the
liver reported in humans.
Soon after the moratorium, studies out of Canada (Birdsell
and others) produced large databases strongly indicating the
incidence of breast cancer was no greater in women with sili-
cone implants as it was in those without. Extensive studies
concerning the autoimmune problems were carried out and
in 1999 a panel for the U.S. Federal Drug Administration
declared silicone was not a factor in the development of
autoimmune diseases.
These reports were not sufficient to allow the products to
be sold on the market in the USA, although other countries
relaxed their regulations readily. The FDA required the man-
ufacturers to submit an extensive study with several thou-
sand patients operated upon by selected surgeons who would
comply with a very rigid set of data requirements. The
implants involved in the study incorporated a triple barrier
shell (methyl-phenyl-methyl) which brought gel bleed down
to near zero, and a more cohesive gel so if it did escape from
the shell it would not drift, as the thinner gel had done, but
remain at the site of shell damage. In 2006, the FDA allowed
selected American manufacturers to resume selling the
newer implants and surgeons who agreed to a long-range
outcomes study could resume using them.
Since that time more advances have been made in implant
design. The cohesivity has been increased so that the form
can remain stable, and the height, width, and projection
ratios are made variable, so the surgeon has a variety of
options depending on the specific needs of the patient.
Other advances in design have included a double lumen
implant with a separate container into which saline can be
instilled giving the surgeons options post operatively to
increase or decrease the size (Becker).
120
As the prosthesis has evolved so have two other concepts:
incision approach and placement location of the implant.
The original approach was at the inframammary fold.
This gave the surgeon a direct view of the operative site and
an opportunity to alter the location of the fold in cases of a
severe short NA-IMF distance. Some surgeons objected to
the scar (but not the case in this author’s experience in over
8,000 cases) and preferred an incision at the periareolar rim.
Objection to this approach arose with the thought of incision
through breast tissue and thus greater contamination and
subsequent increase in fibrous capsule contraction. Although
this is logical thinking recent studies of large numbers of
cases indicate no difference in contracture between the two
sites. Colleagues in Asia are keen on the axillary approach
because of the high likelihood of an obtrusive scar in either
the inframammary or periareolar approaches. In experienced
hands the axillary approach has proven to be excellent, but it
can be a problem when dealing with an aberrant inframam-
mary fold, and a problem as well if one needs to return to the
operating room because of a hematoma.
The second item, placement of the implant, is also one
prompting great discussion. Early on, the only site for place-
ment was behind the gland and top of the pectoralis major.
Because of the problem of fibrous capsule contracture sur-
geons began elevating the pectoral muscle and placing the
implant beneath it giving partial coverage. Others began
elevating the serratus anterior muscle as well. It was found
that the incidence of contracture when the implant was
behind the muscle was one-half that when on top (Biggs). No
good explanation was given but better vascular supply and
less contact with a contaminated breast parenchyma were
suggested as factors. A side benefit of the implant’s retro-
pectoral location was the camouflage of the implant’s upper
rim, a highly important actor in slender patients.
With the advanced implants, fibrous capsule contracture
has been significantly lessened and surgeons are returning to
the retro-glandular position but have found that the upper edge
of the implant still benefits from some coverage. Graf has
reported excellent results by elevating the pectoral fascia and
using it for implant edge cover. Critics have said this tissue is
too thin for any effectiveness but the fascia pulls a portion of
the pectoralis up over the edge of the implant. This author
opines that the retro-fascial placement will be the location of
choice in most patients who are not excessively slender.
The nearly 50 years’ experience with silicone prostheses
has had surgeons dealing with an ever-changing set of
problems. One problem not sufficiently resolved is that of
fibrous capsule contracture. Diminished significantly, yes!
but resolved, no! One conclusion is that the problem is mul-
tifactorial. Early on, talc on the gloves was certainly a factor,
but this was resolved by the removal of the talc by the glove
manufacturers. Blood, cotton, paper were accused and mini-
mized. Gel bleed was accused and is now essentially nonex-
istent. Rough handling of the tissues was accused, now
T.M. Biggs
surgeons operate with far greater delicacy. All these matters
have been extant in the phenomenon of fibrous capsule con-
tracture and have been resolved, but contracture remains a
problem, much less than before, but still with us.
As of this writing focus is on low level infection, caused
either by bacteria introduced at the time of surgery or by a
form of bacteremia accompanying an infection elsewhere (“I
had an awful gastrointestinal problem and two days later my
right breast became tender and inflamed and now it’s hard”).
Our current approach is to utilize a barrage of antibiotics at
the time of surgery and to employ stringent sterility precau-
tions as well. We know that bacteria form in colonies pro-
tected by a self-secreted polysaccharide called biofilm, and
we know this biofilm rejects or disarms the immune cells and
antibiotics. Studies are in process as to how to break through
this biofilm and ultrasound offers some possibilities.
3 Mastopexy and Augmentation
Much has been written about mastopexy and augmentation and
everything written above having to do with the evolution of
techniques has to do with mastopexy and augmentation. It has
been said by this author, by Spear, and others, that it is the most
difficult of all the aesthetic breast surgery operations, because
we are trying to reduce and augment at the same time. A multi-
plicity of techniques are in use, beginning with a straightfor-
ward two stage operation. This author has favored a one stage
procedure but with set rules. One is that the size, or volume, of
the breast with the implant is established first, and then the skin
and nipple-areola complex are adjusted in whatever way the
surgeon is comfortable. This author has an algorithm beginning
with a circumareolar excision of redundancy, to a vertical exci-
sion, to a circumvertical in more extreme cases, to an inverted-
T in extremely extensively large cases (rare). Also important is
to recognize that the middle third of the lower pole must be
dealt with aggressively, preferably resected, in order for a more
permanent aesthetic result to persist.
Augmentation with mastopexy has become a more com-
mon operation as the evolution of aesthetic breast surgery
has evolved and it should be recognized for its uniquely chal-
lenging characteristics. All the elements of anatomical
knowledge, surgical skills, and imaginative surgical creativ-
ity must be brought into play when performing an augmenta-
tion and mastopexy.
4 Aesthetic Aspects of Breast
Reconstruction
The evolution of breast reconstruction has followed that of
the other aspects of breast surgery. With the introduction of
the silicone implant the problem of parenchymal replace-
ment was eclipsed by the need for soft tissue coverage. Thus
History of Aesthetic Breast Surgery
came the latissimus dorsi flap, the TRAM flap, and then a
multiplicity of free flaps. The aesthetic aspects followed suit
and were answered by the utilization of all the creative skills
that had been employed in the other aspects of aesthetic
breast surgery, but an additional challenge has been the sta-
tus of the post mastectomy defect. The extent of the mastec-
tomy and the use of radiotherapy and its consequences have
added another set of factors into the equation of aesthetic
aspects of reconstruction.
5 Fat Grafting
In the 1970s much of our attention was devoted to the bene-
fits of the silicone prosthesis in aesthetic breast surgery. The
1980s brought our interest to the opportunities available
through microsurgery, and the 1990s to the benefits of endos-
copy. It is this author’s conviction that the major progress in
aesthetic breast surgery will be brought about by fat grafting,
and the role of stem cells. Recognizing that the benefits of fat
grafting had been revealed to us by numerous clinicians
(Guerrerosantos, Chajchir, and others) as far back as three
decades ago, it took Coleman with his several necessary
components of successful grafting, with recognition of the
need for vascularization of the graft through microdroplet
injections being the most unequivocal, to make it a recog-
nized and popular key in our quandary of so many locks [3].
The work of Khouri and his simplification and description of
the four essentials (recipient site preparation, acquisition of
graft, processing of graft, and microdroplet distribution of
graft) has brought a new parameter to aesthetic breast sur-
gery [9]. This new parameter is applicable as an adjunct to an
implant, camouflage of contractural defects, and augmenta-
tion of a hypoplastic breast as well. By no means does this
author feel it will totally replace the silicone (or perhaps
other types in the future) implants but it will be a large and
effective key necessary for all advanced aesthetic breast sur-
geons to have in their collection of many keys.
Rigotti, with his large and long experience, relieved us of
the concern over the carcinogenic potential of grafted fat [14].
6 Summary
From the primitive drawings and sculptures of the begin-
nings of recorded time, it has been obvious that the breast is
the foremost external anatomical structure signifying the
female gender. These artifacts also show that through the
jewelry that remains humankind enjoyed adornment of their
bodies. The adornment of the body by its reshaping had to
wait at least five millennia for anesthesia, antisepsis, and sur-
gical skills to advance so the consequences of aging, injury,
121
or illnesses could be altered so this adornment always sought
for could evolve into reality.
As with all other things around us, changes are coming
faster and faster in aesthetic surgery of the breast. Techniques
commonplace only a decade ago have been upgraded or
replaced. We have every reason to believe this trend will con-
tinue. The twenty-first century will bring us advances we
cannot even imagine today, so it seems the most important
way for us to move ahead is to remain curious. Curious as to
what changes can be made and fantasizing about various
options, followed by execution which allows progress that
leads to another door opening prompting us to be curious
again. Such is the way with aesthetic breast surgery. I am
eagerly expectant as the what the next innovations will be.
References
1. Benelli L (1990) A new periareolar mammaplasty: the “Round
Block” technique. Aesthetic Plast Surg 14:93–100
2. Biesenberger H (1931) Deformation und kosmetische operationen
der weiblichen brust. W Mandrich, Vienna
3. Coleman SR, Saboeiro AP (2007) Fat grafting to the breast revis-
ited: safety and efficacy. Plast Reconstr Surg 119(3):775–785
4. Courtiss EH, Goldwyn RM (1977) Reduction mammaplasty by the
inferior pedicle technique. An alternative to free nipple and areola
grafting for severe macromastia or extreme ptosis. Plast Reconstr
Surg 59(4):500–507
5. Courtiss EH (1993) Reduction mammaplasty by suction alone.
Plast Reconstr Surg 92:1276–1284
6. Graf R, Biggs TM (2002) In search of better shape in mastopexy
and reduction mammoplasty. Plast Reconstr Surg 110(1):309–317;
discussion 318–322
7. Hall-Findlay E (2002) Vertical breast reduction with a medially-
based pedicle. Aesthetic Surg J 22:185
8. Hammond D (2006) Reduction mammaplasty and mastopexy: gen-
eral considerations. In: Spear S (ed) Surgery of the breast. Principles
and art, vol II, 2nd edn. Lippincott Williams & Wilkins,
Philadelphia, pp 971–976
9. Khouri R, Del Vecchio D (2009) Breast reconstruction and aug-
mentation using pre-expansion and autologous fat transplantation.
Clin Plast Surg 36(2):269–280, viii
10. Lassus C (1996) A 30-years experience with vertical mammaplasty.
Plast Reconstr Surg 97:373
11. Lejour M (1994) Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg 94:100
12. Marchac D, de Olarte G (1982) Reduction mammaplasty and correction
of ptosis with a short inframammary scar. Plast Reconstr Surg 69:45
13. Mc Kissock PK (1972) Reduction mammaplasty with a vertical
dermal flap. Plast Reconstr Surg 49:245
14. Rigotti G, Marchi A, Stringhini P, Baroni G, Galiè M, Molino AM,
Mercanti A, Micciolo R, Sbarbati A (2010) Determining the onco-
logical risk of autologous lipoaspirate grafting for post-mastectomy
breast reconstruction. Aesthetic Plast Surg 34(4):475–480
15. Sampaio Góes JC (2002) Periareolar mammaplasty: double-skin
technique with application of mesh support. Clin Plast Surg
29(3):349–364
16. Strömbeck JO (1964) Macromastia in women and its surgical treat-
ment: a clinical study based on 1042 cases. Acta Chir Scand 341(Suppl):1
17. Wise RJ (1956) A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg 17:367
 Augmentation Mastoplasty
Andrea Grisotti, Massimo Callegari,
and Domenico De Fazio
1 Introduction
Hypomastia may be originated by an involution of the gland
and adipose tissue of the breast following pregnancy or
weight loss, or may simply consist in a development defect.
In the latter case the lack of volume is present earlier in the
woman’s life, at 16–18 years of age.
Inadequate breast volume can negatively interfere with a
woman’s body image and social and sexual relationships. In
recent years the central role of the body image and of the
personal aesthetics has been growing in importance all over
the world. The demand for breast enlargement has been con-
stantly increasing, and augmentation has become the second
most performed aesthetic operation after liposuction and is
one of the most performed surgeries in Europe.
Because of the cultural background of the patients as well
as on their sexual behavior and body structure, the inade-
quacy of the volume of the breast can be felt by patients dif-
ferently with different demands relating to change of
volume.
For example, in Italy the average weight of the implanted
prosthesis is around 250 g, whereas in the US, it can be more
than 350 g. Obviously, this also depends on the weight and
the general body structure of the patient. In a thin woman of
50 kg, a 250-g implant can show significant augmentation,
while in an overweight patient of 70 kg, the same implant
would lead to a totally inadequate change.
A. Grisotti, MD (*)
Responsabile Unità di Chirurgia Plastica, Divisione
di Chiurgia Plastica, Clinica San Pio X, Milan, Italy
e-mail: agrisott@tin.it
M. Callegari, MD
Private Practice, Milan, Italy
D. De Fazio, MD
Divisione di Chiurgia Plastica, Clinica San Pio X, Milan, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_11
2 History
Breast augmentation has been attempted since more than a
century ago.
Different techniques of augmentation have been used
over the years; they can be classified as follows:
• Injectables
• Autologous tissue
• Implants
2.1 Injectables
During the first years of 1900, reports on paraffin oil injec-
tions in the breast, with the relative complications, began to
appear in the literature. Similar reports have been found as
late as the course of the 1950s and the 1960s.
The extremely severe complications arising from paraffin
injections – induration of the breast with chronic inflamma-
tion – could be treated only with total mastectomy.
During the 1950s and the 1960s, silicon oil has been the
new material, reported at that time as a non-reactive sub-
stance, to be used for injections in the breast. Actually, silicon
oil shows less acute but similar problems, such as induration
of the gland, granulomas and extensive calcifications.
Most of these injections were performed by non-qualified
practitioners, using not only medical grade silicon oil but
also industrial products, not properly sterilized and contain-
ing additives and impurities. Also in these patients mastec-
tomy was the only way to get rid of the silicon and the
infiltrated tissues.
More recently the same non-resorbable fillers (acrylates),
utilized for correction of rhytids in the subcutaneous space,
have been used for breast augmentation for a while and espe-
cially in Eastern Europe; this practice was abandoned as
soon as severe complications such as huge granulomas,
parenchymal induration, distortion of the breast and fistulas
with long standing discharge began to be described [1].
123
124
Later on in the same section of this text we will see how
the idea of using a filler for augmentation – this time a
resorbable one – has come back and is actually practiced,
even if at the moment we have only short-term controls of
the results of this technique.
2.2 Autologous Tissue
When liposuction was introduced in the 1980s, the idea of
transplanting part of the suctioned fat back into the breast
took place. By that time, results proved unpredictable, prob-
ably due to problems related to the fat transplant technique;
furthermore, criticism aroused in relation to the possibility of
negative effects of fat injection on cancer detection with
ultrasonic and mammographic imaging procedures. The
technique was abandoned by most of the surgeons, but came
back in recent years with the aid of new technologies, becom-
ing one of the hot spots of present aesthetic surgery.
2.3 Implants
During the 1950s prosthetic materials made of synthetic
sponges were utilized. Product names were Ivalon and
Etheron. Not long after the implant, the breast became stiff;
the infection rate was high and all the sponges were removed.
In 1963, Cronin and Gerow reported the use of a silicon
implant made of a solid silicon shell with silicon gel filling;
it was built up by the Dow Corning Corporation. The modern
era of breast implants begins at this point.
Silicon, or polydimethylsiloxane, had been used for years
in the industry, also in the course of the Second World War.
It can be produced in the form of oil, elastomer or gel,
depending on the length of the chains of the polymer and
their cross-linking. The oil is made with very short chains
and has liquid properties. It has a widespread use as lubricant
in a variety of pharmaceuticals and food products. It has
been used for years and sometimes is still used for subcuta-
neous augmentation by aesthetic medicine physicians.
Actually, after a number of clinical trials made in the US, its
use has been banned by the medical authorities of most of the
countries.
The elastomer shows the most extensive cross-linking
among the chains; thus, it is produced in the form of a solid
material, suitable to realize implants such as those for the
chin or the malar region or, with a different degree of polym-
erization, the external shell of breast implants.
The gel is produced in a wide variety of cross-linking and
length of the chains. Its consistency can vary from a nearly
liquid state to a rather firm, cohesive gel.
A very cohesive gel gives to the implant the attitude of
retaining its original shape; these are thus called “stabilized
A. Grisotti et al.
implants” and belong to the latest generation of industrial
products in this field.
In 1965 Arion developed in France the first inflatable
implant. It had a silicon elastomer shell, with a leaflet valve to
allow its filling with saline. These implants showed a very
high deflation rate, due to the fragility of the shell and the
malfunction of the valve. In the following years implants
were made in the US with a diaphragm valve and a thicker
shell; as a result, the deflation rate dropped significantly. The
use of different fillers instead of saline (soy bean oil, polyvi-
nyl pyrrolidone, hydrogel, etc.) led to a definite failure and all
the implants filled with alternative materials were removed.
Traditionally, the evolution and all the improvements
related to gel filled implants are referred to as successive
“generations” of products.
The first generation implants were produced in 1963 by
Dow Corning Corporation; these were made of a thick and
smooth shell filled with medium viscosity silicon gel.
The second generation was set for the market in the 1970s;
its alterations were intended to reduce capsular contracture
around the implant, which showed a thinner envelope and a
less viscous gel filling. This resulted in high rate of implant
failure, with gel oozing out. Droplets of low viscosity silicon
gel were bleeding through the thin and permeable shell of the
implant and were commonly found in the periprosthetic
space as oily remnants. Although oozing of gel had never
been put in relationship with systemic diseases, it is probably
one of the factors leading to the formation of capsular
contracture.
Liquid silicon could migrate, being found in the axillary
nodes; on the long term it can infiltrate the surrounding
breast as well as muscular tissues. In most severe cases, the
complete excision of these silicon granulomas could require
a long, complex and bloody procedure, compromising local
anatomic structures.
These problems of frequent shell rupture and gel oozing
led to the development of the third generation implants in the
1980s. These had a multilayer envelope, allowing only mini-
mal oozing of the gel. They proved to be safe and effective.
To decrease the incidence of capsular contracture, early in
the 1970s, implants showing a new surface coating made of
polyurethane were put on the market. These implants –
Meme, Replicon – were used to build up a soft, non-
contracting capsule and were very effective in preventing
any hardening of the breast. The rationale of using a polyure-
thane lining was its role in promoting the ingrowth of the
tissues in the textured surface, thus preventing the parallel
orientation of the collagen fibers and their subsequent retrac-
tion. Most probably, the positive effect on pericapsular con-
tracture is due to the chronic inflammatory response of the
tissues to the polyurethane surface, which can effectively
prevent any organization of collagen fibers. The beneficial
effect showed by these implants on the capsular contracture,
Augmentation Mastoplasty
which is the most frequent complication in breast augmenta-
tion, allowed them to gain in the early 1990s one third of the
whole implant market.
In 1986, trying to obtain the same low rate of contracture,
McGhan introduced a new implant with a silicon textured,
rough, granular surface, mimicking the structural features of
polyurethane.
In 1992 the US Food and Drug Administration (FDA)
requested the implant manufacturers to exhibit more scien-
tific and clinical data about the safety and efficacy of these
gel implants. The result was a ban on the use of silicon gel
filled implants in the US. Thus, gel implants can be used in
this country only in patients enrolled in approved clinical tri-
als, mainly for reconstructive purposes. A few European
countries followed, at least for a while, this so-called “US
moratorium”; presently, the gel implants have no restrictions
all over the world. Starting from 1992 to the present time, a
number of studies have been performed on the potential
adverse effects of silicon. No correlation has been found
between the use of silicon gel implants and autoimmune,
connective tissues and neoplastic diseases. Also the polyure-
thane coated implants were withdrawn from the market in
the US, not in relation to the polyurethane itself, but for their
silicon gel filling. By the way, the safety of polyurethane had
already been questioned and verified. Actually this substance
is slowly metabolized over a period of 8–10 years, and one of
its by-products – the 2,4-toluenediamine – has been found to
be carcinogenic in high doses for the mice. Subsequently, a
huge number of clinical and experimental studies confirmed
the safety and efficacy of polyurethane. By the way, the man-
ufacturers did not file the premarket FDA approval and thus
these implants, widely used all over the world, cannot be uti-
lized in the US. In the early 1990s, just before the FDA mor-
atorium, breast implants were evolving towards the fourth
generation, which was characterized by new standards in
quality controls, new textured shell surfaces allowing a
reduction in the incidence and severity of capsular retraction
and new anatomical shapes, providing a more suitable match
with different concepts of dimensions in breast
enlargement.
3 Breast Implants Today
Breast implants manufactured today can be classified into
three types: saline filled, with a smooth or textured surface;
silicon gel filled, with a smooth or textured surface; silicon
gel filled and polyurethane coated.
Saline filled implants are the only devices utilized in US
for primary breast augmentation since the 1992 moratorium.
They have been improved and now offer a reduced deflation
rate. It is therefore possible to choose from a variety of round
and anatomical shapes, with at least three projection profiles,
125
from low to moderate to high. The feeling offered by these
implants is rather different from that of a normal breast. If
slightly overfilled, as commonly done to avoid the rippling or
waving of the underfilled implants, they feel like a balloon,
with an elastic resistance to compression. Gel implants feel
softer and more natural and this is the reason why all over the
world they result by far the preferred ones. Saline filled
implants should be utilized cautiously in patients with low
body weight and in the subglandular position, because the
lack of good tissue coverage prevents the possibility to dis-
guise the ripples and waves of the implant. Saline filled
implants represent the first choice for patients not completely
convinced of the safety of the silicon gel. This may happen
in patients with collagen and autoimmune diseases, even if
scientific evidence of any correlation definitely lacks.
Silicon gel filled implants are the most frequently uti-
lized, except in the US. Almost all of them are in practice
made with a more or less cohesive gel. The use of non-
permeable shells and the various cross-linkings among the
polymer chains result in minimal or no gel oozing at all. The
high cohesion gel allows the implant to retain its shape after
the positioning, unlike less cohesive gel implants, whose
superior pole will somehow flatten or empty while the patient
is standing. The everyday workhorse is the textured surface
round implant. Currently, it is possible to choose for every
diametric size two different cohesive states and three or four
different projections. Surface texturization can be greatly
different in the various implants. Comparing the implants
actually on the market, we realize that a few of them disclose
an extremely rough surface, which allows a satisfactory
degree of fixing to the surrounding tissues, with immobility
of the implant. The result is an implant that does not move
inside its pocket. This is a totally different result with respect
to the one we obtain utilizing a smooth surface implant,
which remains soft as it moves freely inside a larger pocket.
Low textured implants behave more like the smooth surface
ones, since there is no ingrowth of surrounding tissues and
thus no fixation of the implant. Nevertheless, like the high
textured ones, these implants have shown in several clinical
studies to have a significantly lower incidence of pericapsu-
lar contracture as compared to the results obtained with the
smooth ones. Apparently, the ingrowth by the host’s tissues
is not the critical factor in diminishing the fibrotic reaction
which surrounds the implants. The roughness of the textured
surface of the implant with its subsequent fixation or adher-
ence is of paramount importance for the anatomical implants.
Needless to say, mobility of an anatomical implant is a nega-
tive feature, because of its possible rotation and subsequent
distortion of the breast shape.
To cope with the concept of dimension, introduced in
1993 by Tebbets, and its following evolution, anatomical
implants of different profiles have been produced by various
companies [10].
126
a b
Fig. 1 Breast implants presently on the market. (a) Anatomic implants, silicon gel filled, with highly texturized surfaces. (b) Round implants,
silicon gel filled, with low grade of texturization. (c) Anatomic implants, silicon gel filled, with poliurethanic shell
For any base width, different projection and height options
are offered. From an initial very cohesive and firm gel that
made the augmented breast feel unnaturally hard, corre-
sponding at least to a 2–3 level of the Baker scale, the shaped
implants in recent years are made of softer, more natural gel,
without losing the attitude of shape retention. In these stable-
form devices, the shape is usually maintained also in case of
development of a capsular contracture, unlike what happens
with low cohesive gel, which can easily be distorted, thus
assuming a spherical shape. Polyurethane covered implants
offer the lowest rate of capsular contracture. The reason of
this positive behavior is not clear. The real determinant of the
mechanism seems to be the foreign body chronic inflamma-
tory reaction towards polyurethane, with its definitely casual
fibrosis more than the well organized fibers pattern induced
by different surfaces. This inflammatory reaction subsides
after many years; the polyurethane covering deteriorates and
disappears in 8–10 years. At this point the implant behaves
like a common silicon device, with its usual rate of capsular
contracture.
As already pointed out before, the polyurethane covering
of the implants has been investigated for eventual links with
carcinogenesis. Inside the body, the polyurethane undergoes
a process of biodegradation, leading to the production of
catabolites. One of them is the 2,4-toluenediamine, which in
rodents has proven to be carcinogenic in high doses. On the
other side, it has also been stated that in women bearing
A. Grisotti et al.
implants, toluenediamine in found in non-measurable traces,
produced only during extraction processes not existing
in vivo. Studies performed in the 1990s concluded that the
risk is actually negligible both for the implanted women and
for polyurethane exposed workers.
Outside the US, polyurethane implants are widely used
with success. The inconvenience related to the fragility of
the shell, with possible tears and delamination of the poly-
urethane coating, which was typical of the devices produced
up to 1992, has been definitely solved. Today it is possible to
apply on the implant surface the same mechanical stress that
is exerted on the common textured implants without any risk
of damaging the polyurethane layer (Fig. 1).
4 Breast Augmentation
with Autologous Fat
Today breast augmentation in aesthetic surgery is not limited
to the use of breast implants, as in recent years many authors
have presented excellent clinical results obtained with autol-
ogous fat transplantation. This technique requires the avail-
ability in the patient of localized areas of adiposity, amenable
of implantation.
The advantages of breast lipostructuring are the perfectly
natural appeal of the breast, the absence of any scar and the
great ease in shaping the gland. This is the reason why this
Augmentation Mastoplasty
technique has its elective indication in the treatment of the
tuberous breast deformity. It is a congenital disease which
appears in the course of the breast development, when the
dimensions of the gland progressively increase and the cuta-
neous envelope does not follow adequately that augmenta-
tion. In this way the physiologic shape of the breast is altered,
with a reduction of the base size, and shows an anomalous
projection.
Even in presence of a variety of clinical pictures, the sur-
gical techniques remained unchanged for many years. These
consisted in the correction the bad positioning and the
dimensions of the nipple–areola complex, in the remodeling
of the gland deformity and in the correction of the volume
defect through the insertion of a breast implant. The results
were not always satisfactory and in frequent occasions it was
necessary to perform multiple procedures. On the contrary,
lipostructuring, when applicable, definitely enhances the sur-
gical results.
4.1 Current Techniques
Lipofilling consists in the transferral of adipose tissue, which
is suctioned from certain anatomical locations, such as the
abdominal wall or the thighs, and after processing is reim-
planted in different areas. The results of this surgical proce-
dure were disappointing for a long time, as the injected fat
was inevitably reabsorbed. Surgical techniques evolved up to
1997, when Coleman created lipostructuring, which proved
to be a turning point and gave a definite impulse to these pro-
cedures. The fat is collected using a cannula with a peculiar
blunt tip, capable to keep the damage to the adipocytes to a
minimum during harvesting. Aspiration is performed using a
10 cc syringe which is manually held in a light depression.
The collected fat is left settling into the syringe and then is
centrifuged, in order to get rid of water and oil, obtaining con-
centrated fat. Concentrated fat is thus transferred into 1 cc
syringes and injected into grafting areas using cannulas
smaller than the previous ones. In this way fat is precisely
injected into the receiving areas, where pretunneling allows
best results [2, 4].
Coleman’s technique solves two of the major inconve-
niences of these procedures. The first one is related to the
damage that adipose tissue receives at the moment of aspira-
tion. In previous times, adipocytes were greatly damaged, and
showed limited viability; with the present technique, adipo-
cytes do survive. The second one is related to the need for
transferring fat into well vascularized tissues, so to enhance
its survival capacities: hence the idea was generated of pre-
tunneling the fat tissue with numerous tiny grooves where
small amount of adipocytes is deposited in any of the grooves.
In this way a tridimensional net of tiny tunnels is created,
oriented in different planes, which is called lipostructure.
127
It is also possible to use Carraway’s technique, which
differs from the previously described one in relation to the
processing of harvested fat. It is more practical and rapid, as
fat is only washed with Ringer lactate or saline using a cus-
tom made strainer before its transfer into syringes for injec-
tion. In this way it is possible to prepare larger quantities of
tissue in a shorter time [3].
4.2 The Author’s Technique
The author’s preferred technique is breast lipostructure using
fat tissue enriched with regenerative and staminal cells of
adipose origin (ADRC) [4]. This technique requires the pres-
ence of localized fatty layers; during consultation it is impor-
tant to evaluate the sites to be suctioned and the amount of
adipose tissue that can be withdrawn.
In preparing the operative field the optimization of the
procedure requires that thorax, trunk and inferior limbs are
prepped in the 360° using an antiseptic solution of iodopovi-
done. In this way it is possible to readily change the patient’s
position on the operative table during the procedure, as the
suction can be performed at its best starting with the patient
in the prone position and then turning her on either flank, to
finish the procedure on the patient lying supine. The com-
mon end-point of the various procedures consists in obtain-
ing small bits of vital adipose tissue or clusters of adipocytes.
The technique that can allow the best results has not yet been
established [5–7]. A small number of papers in the literature
underline the differences in vitality and overall quality of the
graft in relation to the various sites of harvesting; other and
more numerous papers confirm that the more frequently uti-
lized sites, such as abdominal wall, flanks, thighs and knees,
release an identical number of viable cells [8]. Other studies
stated that liposuction performed with the Liposutor and
60 cc luer-lock syringes implies a low cellular damage, and
both the analyzed techniques lead to a 98–100 % of cell via-
bility. Other studies on animal models confirm these results,
establishing the presence of identical numbers of adipocytes
independently of the utilized technique [7–9].
The harvesting sites are infiltrated with a 0.5 % solution
of lidocaine with 1:100,000 epinephrine in 1 l of saline.
The amount of the infiltrating solution is related to the
adipose tissue volume to be harvested; usually it corresponds
to a 1:1 volume ratio with the collected fat. The injection is
made with a 14-gauge needle and it is necessary to wait
10 min for the full effect. Liposuction is performed using a
blunt tipped Mercedes cannula, that keeps to a minimum cel-
lular destruction and damage to fibrous septa, neurovascular
bundles and dermis. Pretunneling helps in accepting a greater
volume of adipose tissue for each deposition. The most
important feature of harvesting is the negative pressure that
is applied, as 300–350 mmHg commonly represent the
128
maximum value of negative pressure that can be applied to
liposuction in order to utilize fat for grafting. The 60 cc luer-
lock syringe is maintained under aspiration through a stop-
cock set on the piston, which aids in preserving the necessary
negative pressure.
The ideal approach to adipose tissue separates healthy
adipocytes and regenerative cells (ADRCs) from discarded
cellular components, with minimal air exposure and minimal
handling of the specimens. Also blood, oil and detached cells
must be removed, as they can induce an inflammatory
response that can hamper graft vitality.
The “Celution” device is utilized to enrich the specimen
with regenerative and staminal cells from adipose tissue
(ADRCs).
According to this technique, the first 360 ccs of aspirated
fat are introduced into the apparatus and processed for
120 min. The treatment consists in the digestion of adipose
tissue by the proteolitic enzyme “celase”: as a result, 5 ccs of
a liquid solution containing ADRCs is obtained. The remain-
ing specimen of adipose tissue is inserted in the collecting
bag of the Puregraft system, utilized to perform a lipodialytic
treatment via a bilaminar membrane performing filtration
and exchange flow. The first membrane selectively elimi-
nates detached cells, red blood cells and liquids, including
infiltrating solutions, collected in a waste bag. The second
membrane acts as a filter allowing a “U”-type flow and
dumps waste products, retaining the purified adipose tissue.
It is also possible to reduce the liquid portion of the tissue to
be injected, according to the duration of the filtration period.
Centrifugation is not required; 350 ccs of adipose tissue
can be processed approximately in 15 min.
The adipose tissue collected in the Puregraft bag is
enriched with ADRCs before reinjection. Fat grafting is per-
formed with the “spaghetti” technique, consisting in the
release of small strings of adipose tissue starting in the sub-
cutaneous level and then under the gland, to ensure adequate
projection to the breast. If further volume is required, it is
also possible to inject under the pectoralis muscle.
Using an 18G needle, the epidermis is detached from the
subcutaneous tissue 1 mm under the dermal layer. It is pos-
sible to create an adequate contour of the breasts, with sym-
metric inframammary ridges; this maneuver is particularly
useful in patients with tuberous breasts, in the absence of
cutaneous incisions (Figs. 2 and 3).
4.3 Postoperative Care
Postoperative medication with compression garments
Manual massage and drainage in the areas of fat harvesting
Early and late complications
Edema and bruises
Infections
A. Grisotti et al.
Embolism
Skin contour problems in the harvested areas
Lack of/partial viability of the graft
5 Breast Augmentation with Injectables
In the last few years a special filler for body remodeling
became available; it is an injectable gel consisting in a stabi-
lized non-animal hyaluronic acid solution (NASHA), similar
to fillers in common use for face care; in this manner, its
density is significantly superior. It is utilized for body reshap-
ing: breast enlargement, gluteal and calf enlargement, cor-
rection of post-liposuction deformities and pectoral muscles
recontouring in males. Fillers containing hyaluronic acid are
denser with respect to previous products: they can be utilized
not only to correct wrinkles but also to effectively improve
body contour. The filler can be utilized in the office under
local anesthesia or can require sedation and a few hours of
hospital admission. The technique is simple: small fat depo-
sitions are performed under the gland using 16 or 17G nee-
dles. The involved area is marked preoperatively with the
patient standing; many injections are performed utilizing
numerous entry sites. It is a temporary filler, whose effect
lasts for 12–18 months. It is advisable to perform repeated
treatments to reach the desired result.
6 Surgical Anatomy (Fig. 4)
The breast gland is positioned over the pectoralis major and on
the side of the serratus anterior muscles, from the second to the
seventh rib. It is important to point out that the inferior inser-
tions of the pectoralis major to the ribs are located 1–2 cm
cranially to the inframammary fold. The retromuscolar posi-
tioning of the implant implies the lowering of the inframam-
mary fold and the complete division of the inferior insertion of
the pectoralis muscle. The gland is wrapped by the superficial
fascia, which is made by a superficial and a deep layer.
The blood supply is provided mainly by the external
mammary artery, in the upper lateral quadrant, by the thora-
coacromial artery through the perforating branches as well as
by the intercostal perforating branches from the internal
mammary artery. The vasculature being available abundant,
the incisions and the undermining required for the augmen-
tation mammoplasty never compromise the viability of these
tissues. It is possible that in performing the retroglandular
dissection, the vascularity of the deep layer of the superficial
fascia investing the posterior aspect of the gland is partially
damaged, thus promoting capsular contracture. Performing
the dissection in the subfascial plane, deeply to the superficial
layer of the deep fascia, can be helpful in preserving blood
vessels integrity.
Augmentation Mastoplasty 129

a b

c d

e f

Fig. 2 Patient: body weight 50 kg; height 167 cm; BMI 17.9; 21 years. postop, 10 months after the procedure; (c) Left lateral, preop; (d) Left
Liposuction: trochanters, flanks, knees, abdomen, 1,680 cc (total lateral, postop, 10 months after the procedure; (e) Right oblique (3/4)
volume). ADRCs enriched lipofilling: 385 cc on the left and 355 on the view, preop; (f) right oblique (3/4) postop, 10 months after the
right side. Follow up: 10 months. (a) Frontal view, preop; (b) frontal procedure
130 A. Grisotti et al.

a b

c d

e f

g h

Fig. 3 Patient; body weight 53 kg; height 169 cm; BMI 18.6; 24 years.
Tuberous breasts, with asymmetry. Liposuction: internal thighs, knees,
abdomen, flanks, sacrum, 1,920 cc (total volume). ADRCs enriched
lipofilling: 300 cc on the left and 370 on the right. Six months follow
up. (a) Frontal view, preop; (b) Frontal view, preop, with surgical
marks; (c) immediately after the surgical procedure (the lower pole
shows evidences of tissues detachment in the subdermal plane);
(d) Frontal view, postop, 6 months after the procedure; (e) oblique left
view (3/4), preop; (f) oblique left view (3/4) postop, 6 months after the
procedure; (g) oblique right view (3/4), preop; (h) oblique right view
(3/4) postop, 6 months after the procedure
Augmentation Mastoplasty
Scapular muscle Biceps muscle
Coracobrachial muscle
Pectoralis
major
muscle
Latissimus
dorsi
muscle
Serratus
anterior
muscle
External
oblique
muscle
Fig. 4 Anatomy of the breast: vessels and nerves
The surgical dissection in the site of the implant can
temporary – and very seldom definitely – impair sensation
to the breast, particularly to the nipple. Local nerves pres-
ent wide margins of overlapping: this is the reason why
sensation usually recovers also after wide dissections of
huge pockets. The anteromedial and anterolateral intercos-
tals nerves supply sensation to most of the breast; they are
supplemented by sensory nerves coming from the cervical
plexus in the subclavicular space. Of the greatest impor-
tance is the preservation during the dissection of the
anterolateral branch of the fourth intercostals nerve; it
appears over the serratus muscle lateral to the margin of
the pectoral muscle, penetrates the deep fascia of the breast
and runs medially and then anteriorly towards the areola
and the nipple. The dissection of the external side of the
pocket should be done bluntly, to spare these branches.
Patients requesting a huge breast augmentation should be
warned that the use of large implants can be related with
an impairment of nipple sensation.
7 Planning of the Procedure
Facing the problem of a breast augmentation, before any
decision is taken on the operative technique as well as on the
type of implant to be used, two items of fundamental impor-
tance should be taken into close consideration:
131
Pectoralis
major
muscle
Latissimus
dorsi muscle
III intercostal nerve II intercostal nerve
III intercostal nerve
IV intercostal nerve
IV intercostal nerve
Thoracodorsal artery
Thoracoepigastric Vv
Medial mammary Aa
Lateral mammary Vv
Lateral mammary Aa V intercostal nerve
V intercostals nerve
Serratus anterior
muscle
External oblique
muscle
• The patient’s anatomy
• The results the patient is searching for
The patient’s anatomy should be observed with great
attention: in this kind of surgery, we deal greatly with differ-
ent situations, going from the nulliparous thin patient with
tiny skin and mammary fascial envelope, to the aged over-
weight woman with ptosis of the breasts and looseness of the
skin and tissues. It is obvious that the final result is very
much conditioned not only by the implant, but also by what
we find preoperatively. For this reason at the first consulta-
tion it is necessary to perform a complete assessment of the
patient’s anatomy; only after this step has been passed, we
can proceed with our clinical evaluation and we can try to
understand at our best the patient’s actual desires.
The general shape of the body of the patient should be
noted, together with the body weight, the profile of the hips,
the thickness of the subcutaneous tissues of the thorax, any
asymmetry of the breast tissues and of the height of the
nipples, of the ribs and of the inframammary folds. Similarly,
the elasticity of the skin, the compliance of the tissues at the
inframammary fold as well as at the inferior pole of the gland
should be evaluated, together with the thickness and volume
of the tissues and the breast width. Since an appropriate tis-
sue coverage of the implant is mandatory, we should have a
precise quantification of tissue thickness, to decide the
appropriate location of the device. The pinch test can be used
132
to define the tissue thickness at the superior pole of the gland,
at the inframammary fold as well as medially, at the sterna
margin. The test is performed pinching with two fingers the
skin and subcutaneous tissue over the deep fascia outside the
breast limits (there is no breast parenchyma at this level) and
measuring the tissue thickness with a caliper. Typically, the
minimum thickness that we consider sufficient to prevent the
risk of visibility of the implant borders and their rippling and
waving is 1 cm, corresponding to a pinch test of 2 cm.
Actually, on the long run, also in relation to the weight of the
implant, in many women the skin stretches and the adipose
tissue shows atrophy, with subsequent thinning of the tis-
sues. It is for this reason that implants positioned in the ret-
roglandular space can show up after a few years; this situation
usually requires a reintervention; thus, it should be prevented
through a prudent attitude during the primary procedure,
positioning the implant in a deeper plane. Most of the times,
in thin patients, with inadequate tissue coverage, the retro-
pectoral location is utilized.
At this point we have an idea of where we are starting
from, of what kind of results we can and cannot achieve and
we can talk in a more realistic way to the patient about her
desires.
It is not easy to understand what the patient wants. Very
often she does not have a clear idea of the kind of results she
is looking for, while other patients ask for a precise bra size
to be filled by the new breast, or show a picture of a model or
ask for the same size of a friend of hers that has been aug-
mented by you some time before. It is the surgeon’s task to
explain what can be done and what is actually impossible to
obtain. It is necessary to use everything that can help in the
mutual understanding of what the final result would be.
Displace the patient’s tissues – if there are enough tissues
to allow this maneuver – medially, laterally and superiorly, in
order to fill the corresponding quadrant and simulate a new
profile, while the patient observes the results in a mirror. This
helps in obtaining pieces of information particularly about
the filling of the upper pole and the medial aspect of the
breast that she is looking for.
Ask the patient to bring pictures from magazines showing
women with body weight and thoracic conformation similar
to theirs, with evidence of breasts of volumes and shapes
they like.
Show pre- and postoperative pictures of patients of yours,
with similar body and breast conformation.
Ask the patient to wear an elastic bra and put inside
implants of different volumes and shapes, to have a rough
idea of the projection that can be obtained under gentle
compression.
The maneuver of stretching the breast tissue anteriorly
and then show with your hands the new profile that can be
achieved after filling it with an implant looks inaccurate and
the patient definitely does not understand it.
A. Grisotti et al.
Digital imaging has been utilized as well for determining
the size of the implant and giving a prediction of what the
result could be. As with other parts of the body, it should be
stated that results shown by the computer are not
guaranteed.
Any discussion on the bra-size to be filled postoperatively
is useless, and not infrequently misleading. Actually, differ-
ent patients have different ideas of the effective size of a
given bra cup.
What really matters and will make the difference in the
choice of the dimensions and the shape of the implant is
the patient’s desire about the filling of the upper pole and the
projection of the breast. The width of the breast and the intra-
mammary distance are personal features, only amenable of
minimal variations if we want to keep the implants within the
borders of the breast tissues; in this way it is possible to
obtain the maximal coverage with the minimal palpability as
well as visibility of the device.
In the 1990s Tebbets introduced the concept of consider-
ing all the dimensions of the breast and not only its volume;
the leading measure was the breast width as desired by the
patient and the implant was usually chosen according to this
parameter. Sometimes these criteria lead to the use of exces-
sively wide implants and pockets that, joined with the inad-
equate coverage by the soft tissues, conditioned unwanted
palpability and visibility of the implant edges medially as
well as laterally.
During the last 15 years the idea (Tebbets) that the opti-
mal soft tissues coverage of the implant is extremely
important has been well understood and became popular;
the adequate coverage must be a priority even in respect to
patient’s desires10. If the surgical planning does not respect
this principle, deformities will result, a few of which will
result extremely difficult to correct. The use of very large
implants will enhance the long-term inconveniences
related to thinning, stretching and atrophy of overlying
tissues.
8 Implant Positioning (Table 1)
Dissection of the pocket for the implant can be performed in
four different planes: retroglandular, retrofascial, subpecto-
ral and totally retromuscolar. This latter position, which
requires the mobilization of all the soft tissues from the rib
cage, including the serratus muscle, is obsolete and is rather
used for postmastectomy breast reconstruction.
The retroglandular position, between the corpus of the
gland and the fascial envelopes of the pectoralis major and
serratus muscles, should represent the first choice whenever
the patient’s tissues are adequate. This condition has to be
checked with the palpation as well as with the pinch test,
which should give a result of at least 2 cm. It is considered
Augmentation Mastoplasty
the more natural position, as the added volume is actually
positioned in the same place where it should be, that is the
gland plane. By the way, the shape of the breast comes out
more natural. With respect to the subpectoral positioning,
postoperative pain is by far inferior and physical restriction
for the woman is shorter. Furthermore, the retroglandular
position poses no problems in terms of breast distortion dur-
ing the contraction of the pectoralis muscle; this point has to
be adequately explained to the woman.
In recent years subfascial positioning has became popular.
Actually, it is not clear the reason why if a thin layer of pecto-
ralis fascia is elevated together with the deep layer of the super-
ficial fascia, including the perimysium, the results are different.
A better vascularity of the tissues that cover the implant with a
positive effect on the capsular contracture and a lesser degree
of visibility of the implant edges has been advocated.
Subpectoral positioning ensures a better coverage of the
implant, particularly in the most visible areas, such as the
upper and medial aspects of the breast. It must be utilized
every time tissue thickness over the implant seems question-
able, being aware that aging will worsen the problem of tis-
sues thinning. This decision has to be taken also considering
two unfavorable aspects of this position, such as the move-
ment related distortion of the breast and the more painful and
long postoperative course. The benefits of a better covering
of the implant are invaluable, particularly considering
patients in which the device becomes palpable and visible.
Distortion of the breast while the pectoralis major contracts
can be very fastidious for the patient, particularly when no
manipulation or release of the medial and inferior muscular
insertions has been done. In this case the muscular contrac-
tion pulls the implant superiorly and laterally, leading with
time to the permanent displacement of the device.
Furthermore, the inferior and medial insertions of the
pectoralis muscle, together with its fascial envelope, restrict
the potential expansion of the inferior half of the gland and
Table 1 Implant position
Retroglandular position
Increased incidence of fibrosis
Visibility/palpability of the superior border of the implant
Rippling
Unfit for thin tissues;
Increased evidence of spherical contracture
Suitable for correction of minimal ptosis
Greater motility
No dynamic distortion during pectoralis muscle contraction
Subpectoral position
Low degree of pericapsular fibrosis
Reduced evidence of incidental fibrosis
Less suitable in case of ptosis
Dynamic distortion during pectoralis muscle contraction
133
create a flattening effect that will diminish with time in an
unpredictable way.
It is a long time that the complete release of the pectoralis
insertions along the inframammary fold together with the
partial interruption of the medial ones along the sternum are
recommended; in this way the dynamic distortion is reduced
and a wider expansion of the inferior pole of the gland is
obtained. Actually, the complete release of the inferior inser-
tions of the pectoralis muscle allow to reach the level of the
already cited inframammary fold, that almost always stands
inferiorly to those muscular insertions. The optimal expan-
sion of the inferior pole of the breast may need additional
radial as well as circumferential incisions of the pectoralis
fascia and of the breast tissues. According to the classic tech-
nique, the pectoralis muscle insertions to the overlying breast
tissue are left intact, to prevent an uncontrolled superior
retraction of the muscle, leading to a visible “windowshade”
effect.
More recently a technique of selective release of the
pectoralis muscle, tailored to the patient’s anatomy, has
been popularized and is widely used. This technique of
“dual plane” pectoralis detachment minimizes the dynamic
forces of the pectoralis contraction, offering at the same
time the best possible tissue coverage for the implants in
the more various situations11. The term “dual plane” is
related to the fact that dissection is partly performed in the
subpectoral space and partly in the retroglandular plane.
Dissection is performed not only behind the pectoralis
major, but also directly over it, detaching the muscle from
the gland for a variable distance, according to the required
degree of expansion of the inferior pole as well as to the
level of the ptosis. Included in the technique is also the
tailored release of the pectoralis muscle, with the complete
separation of the inferior insertions and the partial division
of the medial ones. The pectoralis muscle retracts upwards
at different levels, covering only the superior tract of the
implant.
The dissection over the pectoralis muscle is extended up to
the level of the superior border of the areola, in order to cor-
rect the ptosis; in this way the implant can fill the lower pole
of the breast and obtain as much as possible of the pseudo-lift
effect. Dissection should be less extended for a tiny breast.
The retracted pectoralis flap should be sutured again to the
breast parenchyma; this maneuver has to be performed after
the positioning of the implant with the patient seated, in order
to adequately verify the level of replacement.
A modified dual plane technique is characterized by a
horizontal section of the pectoralis muscle 2 cm distally to
the superior limit of the glandular dissection. This will cre-
ate a smaller flap, with still a useful weakening of the infer-
olateral border of the muscle, allowing to eventually
disguise any glandular defect evidenced by the muscular
contraction.
134
9 Preoperative Measurements
and Implant Selection
Along the years, since the new concept of considering
dimensions versus volume spread, extremely complicated
algorithms have been set up for implant selection (Table 2).
These complex formulas have been of great help in the
comprehension of the dimensions concept, caring after
previously omitted details; nevertheless these algorithms can
prove deceptive.
Preoperative measurements strictly essential to ade-
quately select breast implant size are listed here:
1. Base width;
2. Height;
3. Shape;
4. Projection.
Medial and lateral contour. With the patient standing, the
medial and lateral parenchymal boundaries are marked,
pushing slightly the gland inwards and outwards, in order to
make the gland boundaries more evident (Fig. 5).
The inframammary ridge is marked while tractioning the
nipple and pushing at the same time the breast downwards.
This line is temporarily considered the potential new mam-
mary ridge.
Table 2 Implant selection
Width: breast width minus tissue thickness
Height: distance between the expected position of the inframammary
ridge and the superior boundary of the area to be filled up
Shape: if the two measures are identical, a round or anatomical
implant with a round base can be positioned; if the transverse
diameter is longer than the vertical one, an anatomical implant with
oval base is preferred. Using an anatomical implant with oval base,
we can change the shape into an improved aesthetic result
Projection: any base size has 3–4 different projections
a b
Fig. 5 This maneuver allows the surgeon to identify the lateral and medial boundaries of the gland as well as the superior inframammary ridge.
(a) Lateral boundary. (b) Medial boundary. (c) Inframammary ridge. (d) Superior boundary
A. Grisotti et al.
Superior limit. Exerting a light pressure on the inferior
pole of the gland, the superior limit that has to be filled up is
marked (Fig. 5).
Base width. The breast width is measured using a caliper.
Parenchymal thickness has to be subtracted: it can be of one to
two cm, according to the patients’ features. This measured
value identifies in most of the patients the width of the implant
to be utilized, as the device definitely needs to be completely
covered by the breast tissues (Fig. 6). In selected cases, with a
very thick subcutaneous layer, it is possible to select a wider
implant. The main point is that the edges of the device are not
visible nor palpable either medially or laterally under the
thinned tissues.
Height. The distance between the inframammary ridge
and the superior margin of the gland is measured with a cali-
per (Fig. 6).
Nipple-ridge distance at rest and under tension. This mea-
sure is written down by the manufacturer on the implant
package. The under tension measure approximately reflects
the postoperative condition, when tissues are distended by
the new volume; its value gives an indication on the degree
of the implant projection (Fig. 7).
Nipple-ridge distance with elevated arm. This measure is
taken along the median line of the body. Abducting the arm
of 90°, the nipple will be positioned approximately in the
same site it will reach following the implant insertion. That
measure will approximately correspond to the radius of the
implant base, whose value has to be compared with the
already measured transverse diameter.
The position of the new ridge has to be checked. The
nipple-ridge distance on the median line of the body has to
correspond to the sum of the implant radius and the tissue
thickness of about 1–1.5 cm (Fig. 8). The position of the
ridge can be pushed down; obviously, it is necessary to be
sure that the ridge is not too tiny and that it can be lowered
without any deformation or double contour. In thin
patients, the lowering of the ridge often involves an inad-
c d
Augmentation Mastoplasty
a b
Fig. 6 A caliper can be used to measure width and height of the gland. (a) Width measurement. (b) Height measurement
Fig. 7 Measurement of the distance between the inframammary ridge
and the nipple
equate covering of the inferior margin of the implant,
which becomes palpable; the patient needs to be informed
of this occurrence.
If the ridge is tiny and the gland shows an even mild
degree of ptosis, it is important not to push the ridge further
down, and to select among the implants those with a short
superior pole; in this way it is possible to avoid an excessive
and unnatural convexity of the superior part of the breast.
Projection. Implant projection is related to the tissues’
capability of receiving the new volume, and thus to their
135
attitude towards stretching. If under tension the nipple-ridge
distance stretches about 1 cm, the compliance is low; if the
stretch reaches 3 cm, it is possible – and appropriate – to
select a more projecting implant. If under tension the
nipple-ridge distance is superior to 8 cm, the patients have
a ptosis of the breast that will be corrected with great diffi-
culty by the implant.
10 Implant Shape. Round or Anatomic?
Anatomic implants, also called drop devices, have been on
the market since many years, with a great variety of shapes
and projections; many authors consider them of the greatest
importance to obtain in the woman a natural, non-operated
look. The main difference between these implants and the
round ones resides in the superior pole, which is thinner
and can be positioned at different heights with respect to
the circular base; in this way it is possible to avoid an
excessive fullness of the superior quadrants of the breast
and to adapt the volume distribution using implants with
different heights of their superior poles; any incidental
asymmetry between the two sides has to be corrected
(Fig. 9). In various patients the same totally natural non-
surgical look can be achieved using adequately selected
round implants (Figs. 10 and 11).
Obviously it is necessary that anatomic devices maintain
their definite positions, otherwise their shapes can change,
causing overt asymmetries and missing their actual objec-
tive of controlling breast morphology; in these cases a rein-
tervention is usually necessary. The implant surface has to
permanently adhere to the patient’s tissues. This process
136 A. Grisotti et al.

a b

Fig. 8 Measurement of the distance between the inframammary ridge and the nipple, with the arms in 90° abduction. (a) The position of the nipple
(with the patient in abduction) is marked. (b) The distance between the inframammary ridge and the 90° mark on the median line is reported

a b

c d

Fig. 9 Correction of hypomastia and breast asymmetry using anatomi- projection, 125 cc on the left and 150 cc on the right. (a) Frontal view,
cal implants with short and asymmetric superior poles (differing in vol- preop; (b) frontal view, postop; (c) left oblique view (3/4) preop; (d) left
ume and dimensions). This patient shows a low superior pole with high oblique view (3/4) postop
Augmentation Mastoplasty
a b
d
c
Fig. 10 Correction of hypomastia using 250 cc moderate profile round implants: (a) frontal view, preop; (b) frontal view, postop; (c) lateral view,
preop; (d) lateral view, postop
occurs only with highly texturized devices, showing poly-
urethane coverings; nevertheless, in some occasions a net
failure can be expected. Low texturization items create no
adherence between the implant and the tissues and do not
hold the device in its correct position. The implant can
rotate, leading to an unacceptable distortion of the gland
(Fig. 12).
10.1 Memorandum
• A highly texturized device implanted under the pectoralis
muscle is not movable;
• A scarcely texturized or plain implant is movable even in
a subpectoral pocket;
137
• All the glands with subpectoral implants lose their shape
during muscular contraction;
• Retroglandular implants are more often palpable, with
visible margins.
11 Surgical Techniques
Surgery performs previously planned and well determined
actions; from the technical point of view, different phases
can be considered: patient’s marking, surgical access,
implant site or “pocket” fitting, implant positioning; further-
more, the eventual use of a drain has to be evaluated, together
with the use of a postoperative compression or modeling gar-
138 A. Grisotti et al.

a b

c d

Fig. 11 Augmentation mastoplasty using 350 cc medium profile round implants: (a) frontal view, preop; (b) frontal view, postop; (c) lateral view,
preop; (d) lateral view, postop

ment. The surgical table in the operating room must have

adjustable segments, in order to maintain the patient in the
sitting position during the procedure and to evaluate the cor-
rect and symmetric positioning of the implants.

12 Skin Marking

With the patient standing or in the seated position, using a

Fig. 12 A few months after the procedure, the anatomic implant, lack-
ing adherence to the tissues, faced a 180° rotation
dermographic pen the reference points are marked out; these
are the jugular notch, the median line, the inframammary
ridges and, sometimes, the external, medial and superior
boundaries of the gland. These reference points are useful
while dissecting the implant pocket with the patient lying on
the operating table, as in this position the relationships between
the gland and the underlying anatomical planes can be altered.
Augmentation Mastoplasty
13 Surgical Access
At the moment, the most frequently utilized surgical accesses
are the axillary, the periareolar and the inframammary ridge
routes. The axillary route is favored because the scars are hid-
den in the axillary pit, posteriorly to the anterior pillar and thus
is hardly related to a previous surgical incision. The access site
is far from the gland, but with adequate surgical instruments it
is possible to prepare a retroglandular pocket; but if the implant
has to be positioned in the retromuscolar plane, the use of
endoscopic equipment is mandatory, as it greatly aids the con-
trol of the inferomedial corner of the pocket. Furthermore, the
axillary access greatly influences implant selection, as it is
easy to position either empty implants, which can be filled up
with saline later on after their introduction into the pocket, or
round implants; on the contrary, the utilization of large ana-
tomic devices filled with cohesive gel is a rather complex pro-
cedure. In case of reoperative surgery, the axillary route is the
least practical of the various options and invariably forces to
choose a different access.
The periareolar access is positioned in the center of the
breast and allows the operator to easily master the surgical
field while choosing the implant site and during the introduc-
tion of the anatomic implants. If the scar shows a normal
evolution, it is hardly visible, as it rests exactly between the
areola and the skin of the breast. In unusual conditions, when
the diameter of the areola is extremely short, inferior to two
cm, the introduction of implants over 150 cc can be difficult
or even impossible.
The access through the inframammary ridge allows the
surgeon to avoid any passing through the gland. The skin
incision is performed exactly in correspondence of the
planned inframammary ridge, starting from the level of the
nipple and extending towards the external side of the gland
for 4–5 cm. In this way, it is easy to reach the retroglandular
plane as well as the free margin of the pectoralis muscle. It
results rather uncomfortable in defining the superior quad-
rants of the gland, as well as in the positioning of polyure-
thane covered devices.
14 Preparing the Implant Pocket
Once the access is selected, the implant pocket is prepared; it
will extend its span in the retroglandular or in the retrofascial
space, or it may occupy the subpectoral plane or a dual plane.
The dissection should be as accurate as possible and, in relation
to the size of the implant, should not exceed the limits of the
preoperative plan. This is necessary mainly if an anatomic
texturized implant has been chosen, in order to facilitate the
adhesion of the tissues to the device and to limit the cases of
139
dislocation and malrotation of the implant, leading to an
obvious alteration of the gland shape.
The dissection of the retroglandular space is rather sim-
ple, as this plane is easily detachable from the pectoralis fas-
cia and shows a limited vascularization. The dissection is
precisely limited within the marked boundaries.
If a retrofascial dissection is needed, it is better to use a
periareolar access or to make the incision in the inframam-
mary ridge. The dissection of the inferior pole can begin in
the retroglandular space, to become later on retrofascial once
the nipple has been reached and subsequently proceed in the
same plane until the superior pole is reached. In this way the
visibility of the superior margin of the implant is reduced in
patients showing limited thickness of soft tissues at this
level. Electrocautery is utilized for dissection, leaving the
corresponding muscular fibers exposed; the perimysium is
detached as well. The maneuver is difficult due to contrac-
tion of the muscular fibers; a traction applied on the pectora-
lis muscle can make the procedure easier.
Whatever access is selected in order to create a subpecto-
ral space, the free margin of the pectoralis major has to be
searched for and detached from the costal plane, interrupting
all the inferior costal inscriptions as well as the inferior ster-
nal ones for a 2/3 cm tract; this way the inferior pole of the
gland expands more easily. At the moment, the dual plane
dissection is the most widely utilized and also the most artic-
ulated one. It includes a subpectoral dissection joined to a
retroglandular one, limited to the inferior glandular pole or a
little further down; the level is determined by the degree of
glandular ptosis, by the type of implant that has been chosen
as well as by the expansion and repositioning of the inferior
pole that is searched for. If the pectoralis muscle tends to rise
excessively, it is possible to control the level of its
displacement passing a reabsorbable stitch that fixes it to the
gland. In this way it is possible to better evaluate the seated
patient with the implant in the expected position.
15 Implant Positioning
If the surgical site has been correctly prepared, the insertion
of a round implant is actually a simple matter. The main
topic is to avoid a high or low malrotation during the inser-
tion, as this would imply a worsening of the final shape. This
problem can be prevented checking if the little reference
stitches on the base of the implant remain in close contact
with the thoracic wall. Since the very first moment, it is
important to pay great attention to the correct introduction of
the implant, which has to be adequately oriented, as it is very
difficult to move a highly texturized polyurethane covered
device. Prior to the reconstruction of the various planes of
140
the pocket, it is necessary to further control the position of
the reference stitches on the implant, with the patient in the
seated position to verify the shape and symmetry of the
breasts, ready to make all the required corrections.
16 Surgical Drains and Dressings
The actual role of surgical drains is questioned. We use
drains any time when the presence of an even slight hematic
secretion is expected. In this surgical practice built up with
attention to details and great care, it makes no sense to raise
the percentage of seromas and hematomas, jeopardizing in
an unpredictable measure the final result. In our opinion,
vacuum drains reduce the incidence of serohematic collec-
tions and of the related surgical complications. On the con-
trary, compressive and modeling garments are not so useful,
neither to enhance hemostasis nor to maintain the implant in
the correct position: both these results are actually condi-
tioned by the correct preparation of the pocket. A sports elas-
tic bra will be enough.
17 Complications and Their Treatment
The complications of a mammary implant can be due to
alterations of the breast parenchyma, of the devices or of the
interface between implant surface and the parenchyma itself.
Some of them are generic surgical inconveniences, which
may happen after any surgical procedure, that may have
peculiar consequences due to the presence of the implanted
devices; other problems are effectively specific of this kind
of procedures.
Generic complications, requiring a more rapid and spe-
cific approach due to the presence of the implants, include
the hematoma, seroma, infection and wound dehiscence.
The hematoma can enlarge the volume of the pocket, dis-
locating or rotating the device. The physiologic interaction
between the implant surface and the tissues is altered and in
this way the conditions for a periprosthetic capsular retrac-
tion are created. The evolution of the hematoma is followed
clinically, and in case of necessity, performing an ultrasonic
scan to measure the dimensions of the collection. Treatment
most often requires the performance of a surgical procedure
to drain the collection, remove the implant, control hemosta-
sis and proceed to the repositioning of the original device, in
case it has not been damaged by the various maneuvers.
The first choice treatment for a seroma is ultrasound
assisted percutaneous drainage; reoperative surgery is neces-
sary in case of multiple recurrences, to position a vacuum
drain and perform a revision of the pocket.
The infection is an acute event requiring a rapid approach
with antibiotics. In case of failure, the implant has to be
A. Grisotti et al.
Table 3 Specific complications
Fibrosis/pericapsular contracture
Implant dislocation
Implant rupture
Asymmetry
Visibility/palpability of the implant boundaries
Rippling/waving
Distortion
Table 4 Baker scoring system
Baker I: the capsule allows normal softness of the breast, in the
absence of any significant amount of scar tissue
Baker II: capsular contracture forms a palpable scar tissue around
the pocket, yet unvisible
Baker III: capsular contracture is associated to a visible and palpable
firmness of the breast, altering the shape of the gland
Baker IV: capsular contracture is more marked, firm, definitely
palpable and visible and the breast is often symptomatic even in case
of light palpation
removed and the pocket necessitates a thorough cleaning and
usually after these measures there is a rapid recovery. If the
implant is left in place, the tissues colliquation and the con-
sequent fibrosis may induce a serious distortion of the breast.
A new device can be implanted one month after the complete
recovery.
Wound dehiscence can be induced by the ischemic necro-
sis of the wound margins, which can be determined by all the
previously cited complications, by smoking, by the exces-
sive thinning of the tissues or by the use of implants resulting
too large in relation to the patient’s anatomic features. In
case the implant has not been uncovered, the surgical explo-
ration of the wound may be sufficient – eventually with the
addition of a lipofilling course in the perilesional area; on the
contrary, in presence of an exposed device, it is necessary to
perform a surgical revision with thorough cleaning of the
pocket; the wound secretions are cultured to select the appro-
priate antibiotic regimen.
The most frequent among the specific complications
(Table 3) is the periprosthetic capsular retraction, whose
degree can span from moderate to severe, according to
Baker’s classification (Table 4) that consists of four different
levels. Up to date, the exact mechanism of this reaction is
unknown; hematoma, seromas, infections, even at the sub-
clinical level, have undoubtedly their relevance, together
with the peculiarities of the implants surface, as well as sili-
con gel microparticles migrating through the implant wall.
In the last twenty years the progressive qualitative evolu-
tion of the implants has led to a steady reduction in the inci-
dence of this phenomenon. In case of mild to moderate
fibrosis (Baker II-III), the treatment consists in the widening
of the pocket through a radial capsulotomy, together with the
Augmentation Mastoplasty
Table 5 Surgical approach on the capsule and implant selection
Moderate fibrosis: Capsulotomy, round implants, smooth surface/low
texturization (Baker III); freely movable inside the pocket
Major fibrosis: Capsulectomy, anatomic implants with (Baker IV)
polyurethane shell/highly texturization; adhesion to untouched
tissues is necessary to preserve the desired shape
positioning of a low texturized or even smooth round implant.
The pocket has to be enlarged, in order to allow free move-
ment of the implant into the space. Obviously, an anatomic
device must not be utilized, as it can rotate inevitably
determining unwanted variations in the breast profile. It is
necessary to choose this kind of treatment as we do not
expect a major recurrence of the fibrosis very shortly, even if
implants with the same surface covering are utilized.
In presence of severe retracting pericapsular fibrosis
(Baker IV) the best treatment would be a capsulectomy and
the implant of a highly texturized device, even better if with
polyurethane covering (Table 5). All this is done to avoid the
occurrence of a similar retracting response by the tissues: it
is necessary to create a new pocket in healthy tissues and to
use a device which induces a different reaction in the host
tissues. It often happens that as the tissues on the superior
pole of the breast get thinned, the implant actually changes
its position passing from the subglandular to the retropec-
toral plane (the dual plane phenomenon) [12].
Capsulotomy has to be extended towards the intersection
between the basis and the lateral walls as well as in the direc-
tion of the inferior pole of the pocket through radial and cir-
cular incisions selected according to the profile correction
required.
An excessively wide pocket has to be reduced, fixing its
boundaries with braided non-absorbable sutures; the fibrous
shell is removed with great care from the spaces to be
reduced, allowing the development of adhesions (Fig. 13).
Implant dislocation can be due to different factors (hema-
toma, seroma, fibrous retraction), but more often the problem
is related to the confection of an inadequate pocket. Typical is
the low dislocation of the implant, with loss of the inframam-
mary ridge and severe distortion of the breast (Fig. 14).
Capsulectomy is performed via the periareolar or the
inframammary route; an effort is made to separate the cap-
sule from the surrounding tissues using the electrocautery,
scissors or digitoclasie, whatever technique is able to assure
the easiest and quickest results, in the attempt, at least ini-
tially, not to open the implant cavity. A point is reached in
which after the removal of the implant the maneuvers become
simpler; the dissection is determined detaching the capsule
from the surrounding tissues by pulling on the capsular shell
using electrocautery. Hemostasis must be extremely accu-
rate; positioning of drains is recommended.
Particular cases clinically considered as capsular fibrosis
are actually due to pseudomembranes. These are fibrous
141
Fig. 13 Left capsular retraction, with implant dislocation towards the
superior pole; the surgical treatment includes the capsulotomy with
remaking of the pocket; radial and circumferential capsulotomy lines
are reported for reference on the inferior pole. A suture will be per-
formed in the superior pole, to reduce the size of the pocket after the
removal of the involved capsular tract
sheaths that wrap the implant and give it a spherical shape and
a firm consistency. Implants with this kind of covering are
freely mobile inside a normal periprosthetic pocket (Fig. 15).
The traumatic rupture of a mammary implant is a rare
event; the device is rather strong and elastic and is capable of
absorbing energetic shocks without being damaged. Actually,
the life span of a mammary implant reaches 10/15 years. This
kind of rupture is most probably due to the wear and tear of the
shell in relation to aging of the stuff. Sometimes the rupture
induces a capsular retraction; on some other occasions the
break results are clinically unnoticed. Diagnostic techniques
that can evaluate the condition of the implants are ultrasound,
mammography and NMR; all these are accurate procedures,
but are not devoid of misunderstandings. In the event of a posi-
tive diagnosis, it is necessary to inspect thoroughly the pocket,
removing the implant and all the gel eventually spilled into the
cavity. The complete cleansing requires several passages with
surgical sponges soaked with saline. The criteria according to
which the pocket is created, the anatomical plane is selected
and the new implant is chosen are the same as before.
A modest residual asymmetry is definitely physiologic. It
can be due to differences in shape, dimensions and degree of
breast ptosis, or to scoliosis or deformities of the thoracic wall.
The patient has to be noticed of any eventual alteration at the
time of the first evaluation and again during the surgical plan-
ning; it is important to share any decision related to corrective
measures such as the use of asymmetric implants, the perfor-
mance of mastopexy or the maintenance of the basal condi-
tions, limiting the procedure to a mere volume augmentation.
Visibility and palpability of the implants and rippling (for-
mation of wrinkles and waves) must be anticipated in the
142
a b
Fig. 14 Left implant dislocation, with lowering of the inframammary
ridge and evidence of the double bubble sign; the right implant has
already been removed. Corrective surgery includes remaking of the
Fig. 15 The presence of a pseudomembranous wall stuck to the implant
induces retraction, modifies the shape of the device and, if the pocket is
not properly built, allows the implant to be displaced out of any control
planning phase; these problems must be debated, especially
in case where the resulting breast tissue and the surrounding
structures are particularly thin. In an attempt to optimize
implant covering, it is important to choose the right plane for
the superior pole, selecting obviously a retropectoral space;
for the medial and lateral quadrants, as well as for the inferior
pole, the dissection must be limited within the boundaries of
the existing glandular tissue. The correction requires modify-
ing the plane, passing from the space in front the pectoralis
muscle to that behind it; it may be necessary to use different
implants (with smooth surfaces or filled with highly cohesive
gel) or to complete the procedure with lipofilling [11].
Distortion is the extreme consequence of Baker IV peri-
capsular fibrosis; the treatment has been previously debated.
A. Grisotti et al.
pockets, the creation of a new left ridge and the implant of low textur-
ized round devices. (a) Frontal view, preoperative. (b) Frontal view,
postoperative
18 Informed Consent
Explanations contained in the form signed by the patient for
acceptance need to be very clear relatively to a few pecu-
liar aspects. In addition to pieces of information concerning
the generic risks of commonly performed surgical proce-
dures, such as infection, hematoma, dysesthesia, protracted
postoperative pain and delay in wound healing and inadequate
scar, specific risks have to be elucidated. The following repre-
sent a few events that have to be discussed with the patients.
Rupture of the implant: it can be due to damages deter-
mined by surgical instruments, by trauma or simply by the
wear and tear of time.
In case of silicon gel filled devices, the silicon filling can
spill out through the rupture changing form and consistency
of the breast and inducing hyperesthesia. In normal condi-
tions, the gel remains inside the fibrous capsule surrounding
the implant, as at the moment numerous devices on the mar-
ket contain a very cohesive gel with a low degree of migra-
tion within the tissues. If the broken implant is not removed,
as time goes by, the gel can actually pass through the adja-
cent tissues, reaching the axillary lymph nodes.
Usually, in case of rupture of saline filled devices, the liq-
uid that leaks out is directly reabsorbed by the surrounding
tissues.
Capsular retraction: the layer of fibrotic scar tissue that
surrounds the implant can retract, exerting a compression
over it. This can induce a hardening of the breast, with an
antiaesthetic change of its shape and, in extreme situations,
pain. Actually, using implants of the latest generation, this
event appears to be rare. In case of obvious pericapsular
retraction, surgical correction is the right approach, some-
times requiring the replacement of the device.
Augmentation Mastoplasty
Interference with diagnostic imaging: the implant
obscures part of the breast parenchyma, thus inducing a
misinterpretation of the standard mammogram. The radiolo-
gist performing the examination has to be aware of the pres-
ence of breast implants; he must be experienced in the
specific procedure and must use proper X-Ray apparatus, set
for this peculiar form of imaging.
Calcifications: calcium deposits rarely occur in the tissues
adjacent to the implants. This event can be responsible of
hardening of the gland and of pain.
Rippling: the implant surface can develop ripples that
can be noted through the skin determining an unaesthetic
look. Huge folds can irritate or damage surrounding
tissues.
Alterations of sensitivity: the presence of an implant can
alter the patient’s local sensitivity, that can be exalted or
depressed, either temporarily or permanently.
Extrusion: rarely the implant compresses the covering tis-
sues, thinning them until exposition. This event is actually
more frequent in case of excessive size of the chosen implant,
leading to an ischemic compression. Smoking delays the
reparative process and thus can lead to the implant
extrusion.
Lack of satisfaction for aesthetic results: it can be due to
scar related deformities, implant displacement, inadequate
dimensions, lack of symmetry, undesired shape, palpability
of the device, ptosis.
Life of the implants: breast implants are not everlasting
devices; their mean life-span, even in the absence of incon-
testable scientific papers on this matter, is considered to be
around 10/15 years. At any time a surgical procedure can be
necessary for correction and adjustments.
Manufacturers’ guarantee: manufacturers put adequate
care in the engineering and production of the devices, but
they neither guarantee positive results nor exclude inconve-
niences in relation to the clinical use of these implants.
They are not responsible for direct or indirect damages or
expenses deriving directly or indirectly from the applica-
tion of the device. In case of manufactory fault, substitution
of the device is guaranteed and this represents the only
obligation.
18.1 Hints and Tips
In reoperative surgery, anatomical devices must not be used
unless a new pocket is custom made for them.
Positioning the implant consider that the traction leads to
a thinning of the tissues and that this process worsens with
time.
Stiff inframammary ridges must not be pushed down,
otherwise the double bubble phenomenon will ensue.
143
18.2 Personal Preferences
Primary mastoplasty:
• Thin tissues
• First choice: retromuscolar round implants, with low
texturization;
• Second choice: retromuscolar anatomic implants, with
high texturization or with poliurethanic shell;
• Thick tissues
• Suprapectoral anatomic implants, with high texturiza-
tion or with poliurethanic shell.
Secondary mastoplasty:
• In presence of a fibrous reaction: removal of the capsule
and anatomic implants with poliurethanic shell;
• No fibrous reaction: round implants with low
texturization.
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caine. Aesthetic Plast Surg 19(4):335–339
8. Shiffman MA, Mirrafati S (2001) Fat transfer techniques: the effect
of harvest and transfer methods on adipocyte viability and review
of the literature. Dermatol Surg 27(9):819–826
9. Piasecki JH, Gutowski KA, Lahvis GP, Moreno KI (2007) An
experimental model for improving fat graft viability and purity.
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10. Tebbetts JB (2002) A system for breast implant selection based on
patient tissue characteristics and implant-soft tissue dynamics.
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11. Tebbetts JB (2001) Dural plane breast augmentation: optimizing
implant-soft-tissue relationships in a wide range of breast types.
Plast Reconstr Surg 107(5):1255–1272
12. Spear SL, Carter ME, Ganz JC (2003) The correction of capsular
contracture by conversion to “dual-plane” positioning: technique
and outcomes. Plast Reconstr Surg 112(2):456–466
 Cosmetic Breast Augmentation
with Fat Grafting
Daniel Del Vecchio and Roger Khouri
1 Introduction
For fat grafting to emerge as a viable technique for breast
augmentation, it must be safe for patients, yield reproducible
results that satisfy aesthetic goals, and be reliably performed
in 2 h or less. Because of unknown potential effects of fat
transplantation into the breast, such a procedure warrants
careful study. In January 2009, the American Society of
Plastic Surgeons revised their position on fat grafting to the
breasts, and cautioned: “results of fat transfer remain depen-
dent on a surgeon’s technique and expertise” [1]. The use of
fat grafting to the breast has demonstrated photographic evi-
dence of volume maintenance [2]; however, there are cur-
rently no published data to evaluate this on an objective
quantitative basis. Recently, the use of pre-expansion of the
breast recipient site prior to grafting has been reported to
yield objective, quantitative long-term volume maintenance
in both reconstruction and breast augmentation using MRI
[3, 4]. In addition, the use of stem cell-enriched fat grafting
or fat grafting enriched with cell protectants has been sug-
gested to be beneficial to fat graft survival.
The evolution of fat transfer to the breast follows two
merging parallel paths: (a) what we know about adipocyte
transplantation from a basic science perspective, and (b)
what we have seen clinically from the past 30 years in all
types of fat grafting. This is a two-way, iterative street.
Observations by clinicians provide fertile topics for much-
needed basic science research, while observations in animal
models help modify clinical techniques. The purpose of this
D. Del Vecchio, MD MBA (*)
Private Practice, Boston Back Bay Plastic Surgery,
Boston, MA, USA
e-mail: dandelvecchio@aol.com
R. Khouri, MD, FACS
Private Practice, Miami Breast Center, Miami, FL, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_12
chapter is to clearly outline a rationale for the current tech-
nique of mega volume fat grafting to the breast used for cos-
metic augmentation. Such a standard using unaltered
adipocyte graft may serve as a benchmark for comparing
mega-volume fat grafting for breast augmentation using
future core technologies.
2 The Physiology of Fat Grafting:
Current Theories
Like fibroblast survival in skin grafts, the classic “Diffusion/
Angiogenesis” theory of fat grafting postulates adipocytes
survive by oxygen diffusion in the recipient site during the
first 7–14 days following grafting, with eventual micro-
angiogenesis and the formation of a viable blood supply to
the grafted cells. Overcrowding or excessive interstitial pres-
sure in the recipient site is thought to interfere with diffusion,
which leads to cellular death, apoptosis and loss of graft vol-
ume. Just like in a skin graft, early trauma or shearing of the
graft-recipient interface is thought to damage micro-
angiogenesis and decrease graft survival.
An alternative theory of graft volume maintenance is
based on the experimental work of Morrison who demon-
strated adipocyte proliferation and angiogenesis in a perfo-
rated hollow tube filled with a non-viable poly
(D,L-lactic-co-glycolic acid) (“PLGA”) sponge matrix
which was implanted in the groin of rats [5]. In the so-called
Morrison theory, all or most of the transplanted adult adipo-
cytes are destined to die, and act as a non-viable matrix or
scaffold, through which macrophage penetrate and through
which stem cell-mediated angiogenesis and adipogenesis
occurs. Interestingly, Peer’s original 1950 “cell survival the-
ory” postulated that human fat grafts disappeared completely
a short time after transplantation [6] and noted that “small
autogenous multiple grafts had surviving portions that 1 year
after transplantation appeared like normal fat tissue”.
145
146
3 Variables in Mega Volume Grafting:
An Overview
Four clinical categories appear to have significant weight on
the survival of grafted fat cells:
1. Fat Harvesting
2. Fat Processing
3. Fat Grafting
4. Role of the Recipient Site
3.1 Fat Harvesting
Although it has been reported in a histological study that
larger cannula sizes (6 mm) harvest fat with better viability
than with smaller cannulas [7], viability in this report was
measured using cell isolation and counting adipocytes with a
haemocytometer. Such an experimental endpoint only repre-
sents the first step of a multistage procedure which must con-
sider all stages, with the clinical endpoint being long-term (6
months or greater) volume retention.
Smaller cannula sizes theoretically create less donor site
trauma and allow for removal of smaller sized lobules of fat,
which may improve flow characteristics and reduce trauma
during re-injection. An important consideration besides can-
nula size is cannula hole size and number of holes. A 12-gauge
cannula with 6–8 side holes 2 × 1 mm in size can extract a
significant amount of fat despite its small calibre (Fig. 1).
The summation of the surface area of individual openings
on a 12-gauge, 12-hole cannula approaches or exceeds the
hole size of a classic 10 mm one-hole cannula once used in
the 1980s, with much less donor area trauma. Further, each
hole selects for lobules of uniform small size, which are
more likely to flow easily through the injection cannula dur-
ing the grafting phase of the procedure, without the need for
Fig. 1 Varying negative pressure and hole size, the volume of fat flowing through cannulas (measured in cc of fat per 10 strokes) is efficient at
6–12 holes, even at lower negative pressures
D. Del Vecchio and R. Khouri
further processing. The literature regarding the isolated
effects of negative pressure suggests that adipocytes can be
suctioned below 700 mmHg without undue trauma [8].
While a standard liposuction machine can generate up to
1 atmosphere (atm) (760 mmHg) of negative pressure, a
60 cc syringe connected to an in-line manometer can also
generate nearly 1 atm of negative pressure (Fig. 2). The adi-
pocyte is impartial to the source of negative pressure; it is
likely the absolute pressure and not the source of this pres-
sure that makes a difference in adipocyte trauma.
Animal studies have not demonstrated superior donor
site fat based on anatomic location [9], and clinically we
have not observed anatomic location of the donor fat to be
of significance in terms of volume retention. What is more
important to consider is the relative abundance and require-
ments of donor graft in each individual case, and the surgical
plan should aim to avoid or minimize donor site deformi-
ties. It may turn out that adipocyte cellular size, which varies
in different body regions and also among different patients
may be a more important variable. Larger cells have a higher
likelihood of mechanical cell membrane damage during
Fig. 2 A syringe can generate close to 1 Atm (30 in. = 760 mmHg) of
negative pressure
Cosmetic Breast Augmentation with Fat Grafting
extraction, and it may be this variable of cell size relative
to cannula hole size that is more important than the specific
area on the body used for harvest per se.
Another variable of unknown importance in fat harvesting
remains the negative impact of air exposure [10]. Despite its
widespread mention, there is a paucity of scientific data quanti-
fying the effect of air exposure on adipocyte viability [11].
Techniques of fat processing range from drying fat on Telfa
Rolls (high air exposure) to completely closed systems employing
intravenous tubing, three-way stopcocks and IV bags for collection.
3.2 Fat Processing
Peer’s cell survival theory of grafted en bloc fat dates back
over 50 years and suggests the number of cells transplanted at
the time of transplantation may correlate with the ultimate fat
graft survival volume [12]. After Ilouz’s breakthrough applica-
tion of liposuction [13], fat became available in a fragmented
form. The cell survival theory of solid fat transplantation may
have influenced the use of high-speed centrifugation as a
potential strategy for effective fat grafting. Historically, the
penchant for centrifugation may have arisen from the need to
graft as much adipocyte biomass as possible into a limited
space. Although centrifugation can process highly concen-
trated fat, there are potential problems associated with it:
• The cells may be damaged due to high G-forces [14].
• It is a time and labour-consuming process.
• High fat concentrations may cause clumping and more
difficult flow during re-injection.
3.3 The Confusion of “Percent Yields”
One of the most confusing metrics in fat grafting is a lack of
standardization when one discusses “percent yields”. Once
fat is lipo-aspirated as donor graft there is an infinite number
of different concentrations of adipocyte volume relative to
Fig. 3 Equalization of hole size. The opening in the 3 mm,
9-hole aspiration cannula (top, centre) is nearly equal in size
to the hole opening in the 16-gauge blunt tipped side hole
injection cannula (bottom), reducing resistance to flow on
injection
147
non-adipocyte volume (blood, serum, crystalloid) that can be
reached prior to grafting the recipient site. Unless the con-
centration of adipocytes in the grafted material can be
accurately measured and unless the process of fat concentration
is standardized, one cannot reliably measure the percent of
adipocyte volume that survived grafting. In an effort to move
towards an acceptable technical standard and to allow for
better comparison of volumetric data in clinical series, care-
ful documentation of the following data should be performed
in mega-volume fat grafting patients:
• Obtain a baseline mammogram of the breast
• Prior to expansion, objectively document breast volume
(MRI, 3D imaging, or both)
• Document the process used for crystalloid separation (decant-
ing, low-speed centrifugation, high-speed centrifugation)
• Document the volume of processed material grafted in cc
• Objectively document the post graft volume of the breast
at 6 months or more (MRI, 3D imaging, or both)
3.4 Fat Injecting and Shape-Modifying
Techniques
The selection of an injection cannula used in mega-volume
fat grafting follows similar principles to those of harvesting.
Small-gauge cannulas theoretically reduce trauma to the
breast recipient site, which reduced the risk of bleeding,
hematoma, and poor graft oxygen diffusion. The hole size of
the injection cannula should match closely with the hole size
of the aspiration cannula. By matching hole sizes, the
selected size of the harvested lobules of fat are more likely to
flow easily through the injection cannula without blockage
or undue resistance (Fig. 3).
There are currently two methods of injecting fat in a man-
ner that seeks to increase dispersion and surface to volume
contact with the recipient site – the “Mapping” technique and
the “Reverse Liposuction” technique. Despite using these dif-
ferent techniques, the authors’ independent long-term volume
148
maintenance is essentially the same, each demonstrating an
average increase in breast volume of 250 cc on average at 6
months by quantitative volumetric MRI imaging.
3.4.1 The Mapping Technique
Donor cells have the highest chance of survival with the
technique that best ensures an even, three-dimensional dis-
persion of the fat. The mapping technique involves the use of
small (3–5 cc) syringes handheld and connected directly to a
16-gauge blunt curved side-hole cannula. Markings are made
in the recipient areas to aid in a systematic, diffuse and even
injection of the entire recipient. Eight to ten circum-
mammary and four circum-areolar entry points are usually
made with a 14-guage hypodermic needle (Fig. 4). Through
each entry point the 15–20 cm long cannula makes multiple
tunnels that fan out radially and injects 1–2 cc of fat upon
withdrawal. The cannula is then inserted into another
adjacent entry point and the process is repeated to yield a
3-D weave that evenly crisscross covers the recipient space.
Multiple levels of graft are deposited, deep from the base
of the breast just above the pectoralis fascia, to the subcuta-
neous space immediately subjacent to the dermis. Direct
injection of fat into the dense parenchyma of the breast is
never performed. This technique is deliberate and exact but
does take time. In addition, it requires the operator to deploy
the plunger and withdraw the needle at the same time.
Overall, the mapping technique may be more suitable for
surgeons beginning mega-volume fat grafting for breast aug-
mentation because it is more exact and deliberate. For breast
reconstruction, it is clearly beneficial, especially in scarred
Fig. 4 Markings for the mapping technique of fat injection on the
expanded breasts. 8–10 circum-mammary and 4 circum-areolar needle
puncture entry sites with radially fanning tunnels from each site provide
a well-diversified insertion of the grafts
D. Del Vecchio and R. Khouri
areas caused by mastectomy and/or irradiation where a care-
ful and deliberate graft placement is necessary.
3.4.2 Reverse Liposuction Technique
The reverse liposuction technique seeks to evenly disperse
the fat into the subcutaneous and non-breast parenchyma in
as efficient a manner as is possible. Six to eight needle inser-
tions are made using a 14-gauge needle on the breast, along
the infra-mammary fold (“IMF”) and spaced 4–5 cm later-
ally towards the axilla. The IMF insertions are usually made
I cm below the native IMF as this will descend 1–2 cm, simi-
lar to the effect seen in augmentation with breast prostheses.
Using a straight, 15 cm blunt side hole, 16-gauge needle
loaded directly onto 60 cc syringes, the fat is injected using a
controlled “to and fro” liposuction movement with constant
light depression on the plunger. With every pass of the needle
the direction is changed slightly to create a fanning pattern of
vectors. This is repeated in each different insertion site and at
multiple planar levels from the base of the breast. The axil-
lary insertion is also used to place graft in the sub-muscular
position and this approach is felt to be the safest method of
navigating the sub-pectoral space. The rate of graft insertion
in this technique should be 2–3 s per cc, which results in a
2–3 min/60 cc of fat rate, or a 300 cc per breast grafting ses-
sion performed in 10–15 min on each breast. The reverse
liposuction technique is more time efficient and can be uti-
lized in cases where there is no internal breast scarring, no
dense adherence of skin to the chest wall, and where the
breast is adequately expanded. Another potential benefit of
the reverse liposuction technique is that 60 cc syringes gen-
erate lower maximum pressures than do 5 cc syringes, which
generate higher pressure. Therefore, if there is a blockage of
flow along the insertion needle due to clumping, this will
occur at a lower pressure using a 60 cc syringe, with less
potential damage to the grafted cells and less likelihood of
pushing the blockage through, creating a bolus.
3.5 Shape Modification Using Three-
Dimensional Meshing: “Rigottomy”
Once the fat is grafted, the internal parenchyma is under
higher pressure. Contour irregularities due to internal liga-
mentous tethering can be manifest, especially seen at the
interface between the natural inframammary fold and the
newly augmented breast mound. A technique first described
by Gino Rigotti to release subcutaneous scars in breast
reconstruction with fat grafting, called three-dimensional
mesh release, or “Rigottomy” is a powerful technique that
can change breast shape. This technique, like meshing a two-
dimensional skin graft, releases contour deformities of the
breast parenchyma in three dimensions. Grafted fat immedi-
ately fills the release and maintains the altered shape.
Cosmetic Breast Augmentation with Fat Grafting
4 The Role of the Recipient Site
in Fat Grafting
Negative pressure on the breast creates internal expansion of
the breast parenchyma by drawing in more fluid and by
increasing the size and calibre of blood vessels.
The authors postulate that BRAVA enhances fat grafting
results by five main effects:
Bigger potential spaces available for overall volume of graft.
Reduces the demand on adipocytes to create the expansion,
which may kill them.
Augments tension on internal constrictions and scars, so
breast shape can be addressed.
Variables that are time consuming (e.g. centrifugation)
become less demanding.
Angiogenesis effect may increase recipient site oxygen ten-
sion and better graft take.
The use of the VAC® device has markedly improved
outcomes in many types of difficult wounds, by clearance
of bacteria and reduction in fluid volume [15]. In open
wounds, micromechanical forces such as vacuum elicit
tissue deformation forces that stretch individual cells,
thereby promoting proliferation in the wound microenvi-
ronment. The application of micromechanical forces on
cells has been demonstrated as a useful method with
which to stimulate wound healing through the promotion
Fig. 5 Preoperative BRAVA expansion and 3 weeks postoperative BRAVA expansion, immediately prior to grafting. Note the volumetric increase
is 3–4 times that of the pre-expansion state. A total of 380 cc of fat was injected in this case into each breast
149
of cell division, angiogenesis, and local elaboration of
growth factors [15, 16]. The deformational forces of the
VAC® device are consistent with this mechanism of action
and are similar to the negative pressure of BRAVA. Pre-
expansion to the breast may therefore be more than just
“increasing space”. Negative pressure therapy to the
breast may demonstrate similar effects of angiogenesis,
cell division, and up-regulation of growth factors in the
breast recipient site (Fig. 5).
5 Technique
5.1 Patient Evaluation and Selection
Anatomically speaking, an ideal patient for BRAVA pre-
expansion and mega-volume fat grafting is a patient who
has had one or more children, in whom there is breast
deflation but not frank ptosis, and in whom there is an ade-
quate amount of donor fat. Patients who have had children
have already undergone one or more episodes of parenchy-
mal expansion with breast milk. Engorgement of the
breasts creates a natural stretching and loosening of the
parenchymal ligaments. Although this may have occurred
years prior to the BRAVA expansion, this prior expansion
allows an easier, more rapid expansion when BRAVA is
applied, given the same degree of negative pressure and
time used.
150
Thin patients with small breasts often do not desire a
major volume increase; therefore, even thin patients may be
candidates for BRAVA fat grafting, as long as realistic expec-
tations are discussed preoperatively (Fig. 6).
Dense parenchyma breasts will expand with more diffi-
culty than soft, multiparous breasts. Patients with dense
parenchyma breasts must be coached effectively to increase
the negative pressure on the BRAVA domes to achieve an
adequate expansion preoperatively. Often, the dense
parenchymal breast will expand more in some areas, like the
peri-areolar region, than in others. This will result in a dou-
ble bubble constriction deformity that must be released at the
time of surgery (Figs. 7 and 8).
Constricted or tuberous breasts require aggressive expan-
sion, and following this the constrictions can be released
mechanically using a three-dimensional mesh release:
this patient will require aggressive release of the inferior
mammary fold using a three-dimensional mesh release
“Rigottomy” at the time of fat grafting.
5.2 Patient Selection
There are two compliances: the patient’s tissue and the
patient. A properly motivated patient is vital for the success
of pre-expansion which in turn is vital for the success of the
fat grafting procedure. The surgeon and the patient must be
equally committed to the pre-expansion process for a suc-
cessful result.
Despite adequate screening for compliant behaviour,
some patients who initially intend to proceed with BRAVA
pre-expansion and grafting will simply fail to expand. In
Fig. 6 Smaller breasts, even if doubled in volume are still not very large
D. Del Vecchio and R. Khouri
these patients, fat grafting is not performed until satisfactory
expansion is obtained. It is far better to postpone a procedure
after a failed expansion than it is to move forward and per-
form what may result in a failed operation. Without adequate
pre-expansion, the results of fat grafting to the breast may be
limited to small graft volumes (100 cc or less) that do not
exceed high interstitial pressures in the recipient site. In
breast augmentation, such volumes are rarely adequate to
achieve core tissue projection replacement. Therefore, if a
surgeon grafts a patient who has failed to expand; it is likely
that repeat procedures will be necessary. Inevitably, this will
be interpreted as a failure of the procedure resulting in repeat
procedures, a dissatisfied patient, or both.
5.3 Preoperative Preparation
of the Recipient Site
Mammograms are performed on all patients to obtain a base-
line screening for breast pathology. Patients have three-
dimensional MRI or three-dimensional photographic
imaging to determine pre-expansion baseline volume
(Fig. 9). Before expansion begins, candidates for the proce-
dure are given a specific “goal volume” to achieve and agree
they will follow the expansion guidelines. On a volumetric
basis, a quantitative doubling of breast volume is the mini-
mum goal set.
The BRAVA bra is then fitted on the patient by the nurse
or by the surgeon, who makes certain that the patient can
apply the bra and achieve the suction on her own. The
BRAVA bra comes in several dome projections and in sev-
eral base diameter sizes and the correct size must be selected
Cosmetic Breast Augmentation with Fat Grafting 151

Fig. 7 Smaller dense breasts. After expansion, there is a step-off deformity at the breast, areolar junction due to lover resistance of the areolar
tissue compared to the breast tissue. This patient will require three-dimensional mesh release intra-operatively to address this deformity

Fig. 8 Constricted breasts, pre-expansion and post-expansion with BRAVA (no fat grafting yet)
152
Fig. 9 MRI of the breasts with contrast in a patient before and after 3
weeks of 10 h/day Brava® use. There is significant expansion of the
breasts with the creation of a larger and more fertile recipient matrix
Fig. 10 A manometer fitted in the BRAVA system allows patients to apply
specific negative pressures for different intervals during the expansion
period. This has increased compliance and the efficiency of expansion
for each patient. It is important to educate the patient how to
apply the bra so there is no room for error or lack of compli-
ance during the expansion process. We also incorporate a
manometer into the BRAVA system so patients can be
directed to expand daily, following a specific programme of
duration and intensity of expansion (Fig. 10).
D. Del Vecchio and R. Khouri
which will allow more fat grafts to be placed. Note increase in number
and size of blood vessels
5.3.1 Clinician’s Endpoints for Expansion
Surgery is not guaranteed unless the patient adequately
expands. Patients are seen weekly in the office to monitor
compliance and to quantify the expansion progress, and to
make necessary corrections to the programme. A standard
doubling of breast volume by three-dimensional imaging is
realistic and is usually obtained in 3 weeks in patients who
follow the programme of expansion. Although this process is
budgeted to take 3 weeks, it is not as much a matter of time
as it is a matter of adequate volumetric expansion. Some
patients simply expand faster and better than others. In our
practice, we have seen patients expand to four to five times
initial volumes in 3 weeks, while in other cases, we have
seen patients who had little or no expansion after the same
period of use (Figs. 11 and 12). The duration of use in terms
of hours per day [8–10] and the negative pressure during use
are the two variables that can be modified to achieve the
desired expansion.
Using a postoperative questionnaire, our patients reported
difficulties in compliance with the BRAVA bra in decreasing
order, as follows: (1) appearance of the domes prohibiting
use outside the home; (2) difficulty applying a suction and
(3) skin irritation at the base of the dome. Although these are
real challenges, with proper support and patient education
successful and effective expansion is possible.
5.3.2 Patients’ Endpoints for Expansion
It is also important to educate the patient as to the extent of
the desired expansion. Often, patients think they need to
expand to their desired breast size and then stop. This is not
optimal. The BRAVA expansion should be greater than the
desired volume, so there is a much larger potential space cre-
ated by BRAVA compared to the desired volume of fat to be
grafted. We have developed the “1-2-3 Rule”, for our patients
so they can easily understand the endpoints of expansion
while they visually monitor their progress at home (Fig. 13):
Cosmetic Breast Augmentation with Fat Grafting 153

Fig. 11 A 21-year-old with virtually no breast tissue (left) and (right) 3 weeks after effective breast expansion using BRAVA. The increase in
volume is 500 % quantified by three-dimensional imaging

Fig. 12 A 38-year-old achieved only a doubling (200 % increase) of breast volume with pre-expansion. This patient was deferred surgery at 3
weeks. It took 5 weeks to achieve this expansion

Fig. 13 The “ 1-2-3 Rule”: a patient who wants to double final volume, must triple in expansion

“1-2-3 Rule” IF you are a “1” and you want to be a “2”,
you must expand to a “3”.
6 Procedure
6.1 Summary of Surgical Technique
Patients arrive in the operating room on the day of surgery
wearing their BRAVA Bra. Preoperatively, the patient is ini-
tially marked for areas to be suctioned, and the breasts are
marked circumferentially for areas of proposed needle inser-
tions. Any constricted areas are outlined for planned release
using a percutaneous needle. Markings are placed at 8–10
proposed sites, circumferentially around the breast. Once
markings are completed, the BRAVA Bra is re-applied. Once
in the operating room under general anaesthesia, the patient
is positioned supine with the domes still in place and under
manual bulb suction. The anaesthesiologist monitors the
suction intermittently during the liposuction phase of the
procedure, so the negative pressure can still be applied to
maximize the recipient site space.
6.1.1 Harvesting
Liposuction is performed using a 12-gauge multi-hole (9–12
hole) cannula. For faster harvesting, 3 and 3.5 mm diameter
cannulas are used. Smaller cannula sizes leads to less subcu-
taneous tissue trauma, faster recovery, and smaller fat lob-
ules which result in better fat flow and less clumping.
Multiple holes lead to more efficient and faster fat removal.
Two collection techniques are currently employed:
154
Syringe Collection Method (Khouri). Using a spring-loaded
60 cc syringe attached to a 100 cc sterile IV bag by intra-
venous tubing, fat is harvested in a completely closed sys-
tem. There is no exposure to air whatsoever. Excessive air
exposure is known to be detrimental to adipocyte survival.
This technique initially collects the fat into 100 cc IV
bags, which is efficient for the next step in the process
(Fig. 14).
Machine Method (Del Vecchio). Using a sterile “in-line”
container, fat is aspirated at lower than 1 atm (500 mmHg)
suction by attaching a sterile clear collection canister to a
standard vacuum machine off the sterile field. A 3-mm
9-hole cannula with a wide handle and ribbed connector
end is used to attach to the liposuction tubing. Maximal
negative machine pressures are avoided when using this
technique and vaporization of the fat in the collection
canister is to be avoided at all costs. This technique ini-
tially collects the fat into 1,200 cc canisters and can be
performed with existing equipment used in an operating
room (Figs. 15 and 16).
Once the fat is collected, two general methods for remov-
ing unwanted crystalloid are employed:
“Bag Centrifugation” (Khouri) Method. Previously men-
tioned 100 cc IV bags are hung on a hand-spun 5–1 gear-
ratio spinner and centrifuged at low RPM (approximately
30 G) for several minutes. The resultant crystalloid is
tapped off and the fat is ready for re-injection (Fig. 17).
Fig. 14 Syringe method of fat harvesting. Via a specialized stopcock,
the fat is transferred via the intravenous tubing to a 100 cc sterile IV
collection bag on the field
Fig. 15 A 3 mm multi-hole cannula fused to an ergonomic
handle reduces operator fatigue and reduces instrument
breakdown at the handle-tubing interface
D. Del Vecchio and R. Khouri
“Large Syringe” (Del Vecchio) Method. By changing several
in-line collection canisters during the machine liposuc-
tion, the canisters are allowed to stand for 10 min, allow-
ing fat to separate from crystalloid. This fat is then drawn
up into 60 cc syringes directly from the collection canis-
ter, and placed in a mega volume centrifuge. Additional
low G-force centrifugation of these 60 cc syringes is
optional (Figs. 18 and 19).
As stated previously, the emphasis on ultra-concentrated
fat is less important the greater the overexpansion of the
recipient site space using BRAVA. Overexpansion of the
recipient site affords the opportunity to inject less concen-
trated fat. This less concentrated fat is theoretically less trau-
matized, flows better, disperses better because it is less
concentrated, and finally takes less operative time and man-
power to process. The emphasis on “overcorrection” of fat
grafting with resultant overcrowding, interstitial hyperten-
sion and fat necrosis can now be applied to “overexpansion”
of the recipient site pre-fat grafting.
Washing the cells with saline is avoided, as it is felt this may
only remove components such as stem cells and growth factors
Fig. 16 Depiction of the “In-line” system with left hand tubing going
to the cannula, the right hand tubing headed off the field to a liposuction
machine. The sterile canister on the field collects the fat
Cosmetic Breast Augmentation with Fat Grafting 155

Fig. 17 Bag centrifugation tech-

nique. The bags are already filled
with fat and simply spun at low
RPM by a handheld device on a
sterile side table. This takes min-
utes to prepare, versus hours for
high speed centrifugation

Fig. 18 In the “Large Syringe”

method, the passive use of 1G
separates the fat from the
unwanted crystalloid by the use
of stiff collimated containers –
the canister and then the 60 cc
syringes. This occurs passively
and takes minimal additional
time

from the fat slurry. Once the fat is separated from unwanted
crystalloid, injection into the breast begins. Injections were
performed using a 15 cm Coleman side hole needle.

6.1.2 “Mapping“ Technique (Khouri)

Fig. 19 60 cc syringes loaded onto sterilized low G-force bucket han-
dle centrifuge. Spinning decanted fat for 3 min at 40–50 G results in
15–20 % additional crystalloid removal, as shown
If a closed-system bag collection, bag centrifugation tech-
nique is used, the fat is simply drawn back out of the IV bags
using a 3 or a 5 cc syringe, and injected through 10–12
circumferentially placed needle sites. Care is taken to dis-
perse the graft as much as possible and to inject upon with-
drawal of the needle along an axial track. Fat is deposited
from the base of the breast outward, beginning in a sub-mus-
cular plane, then proceeding above the fascia, and then subcu-
taneously in increasingly superficial planes. Direct injection
into dense breast tissue is not performed. This technique is
more accurate, deliberate, and is recommended for those who
are initially performing fat grafting to the breast.
156
6.1.3 “Reverse Liposuction” Technique
(Del Vecchio)
If fat has been harvested and collected using the machine and
Large Syringe technique, the fat is already in 60 cc syringes.
These syringes are simply loaded onto the Coleman needle and
injected into the breast. Multiple insertion holes are employed
in a pattern around the breast periphery. Insertions along the
medial upper quadrant are generally avoided to reduce the pos-
sibility of pigmented large needle scars, as this is the part of the
breast often seen in low cut clothing. Using a “reverse liposuc-
tion” technique, gentle pressure is placed on the plunger of the
60 cc syringe and the needle is inserted and removed in a rela-
tively rapid fashion along multiple axial directions.
The maximal pressure generated in a 60 cc syringe is
lower than that of a 3 or a 5 cc syringe. Potentially, there is
felt to be less pressure and trauma on the adipocytes using
the larger syringe. If the graft is placed at a rate of 1 cc of
volume in 2–3 s, this results in 2–3 min per 60 cc syringe of
fat, or 10–15 min to augment 300 cc of volume into each
breast.
6.2 The Aesthetics of Breast Size and Shape
6.2.1 Immediately Post Grafting:
A Paradigm Shift
There is a major paradigm shift between what a surgeon
should expect from an aesthetic perspective following pros-
thetic breast augmentation and augmentation using mega
volume fat grafting. Using breast implants, the “on table”
aesthetics can be critically examined for size, symmetry and
position and are more “WYSIWYG” (what you see is what
you get). In contrast, the immediate “on table” result with
mega volume fat grafting represents the first stage of a
dynamic process. First, there is a volume of interstitial fluid
Fig. 20 Immediately after fat grafting, the injected fat provides an inter-
nal traction effect to help identify specific areas of deforming scar or liga-
mentous bands, as seen at the inframammary fold in this patient (left).
D. Del Vecchio and R. Khouri
represented by the expansion itself and crystalloid in the
donor fat that will re-absorb in the first 3–5 days post graft-
ing. The surgeon should not be too concerned with the
appearance of breasts that look too “large” on the table, but
should focus on the volume of material that was grafted.
Secondly, because the augmentation is intra-parenchymal
as opposed to single cavity volume enhancement seen in
implants, there are more on table surface irregularities that
resolve in the early postoperative period and require no addi-
tional manipulation.
“Three-Dimensional Needle Band Release”, or
“Rigottomy” Technique: when external negative pressure is
placed on the breast, BRAVA pre-expansion may accentuate
breast contour irregularities that are due to infra-mammary
fold constrictions, tuberous breast constrictions or internal
scars in the breast (Fig. 20). It is important to recognize these
irregularities in the OR while the patient is still on the table.
Breast shape can be addressed in augmentation patients,
especially double bubble contour deformities that occur
along the inframammary fold.
7 Postoperative Management
In the first 24 h post grafting there is no external compression
or negative pressure used. Patients are placed in standard
girdles as for routine liposuction. Beginning at 24–48 h after
grafting, patients are placed into BRAVA domes, which are
placed under low suction for a period of 14–21 days. The use
of BRAVA in the postoperative period may act as a splint.
The importance of immobilizing a split thickness skin graft
postoperatively is well recognized. Conversely, the low neg-
ative pressure exerted by the BRAVA bra may help immobi-
lize the fat cells and aid in neovascularization to the graft. In
any event, application of the domes in the postoperative
After inserting a 14-gauge needle and releasing the scar bands the irregu-
larity is released and the fat immediately fills the space created, changing
the shape to a more aesthetic result at 3 days postoperative (right)
Cosmetic Breast Augmentation with Fat Grafting
period certainly protects the breast from external trauma,
which could serve to shift the graft and potentially disturb
neovascularization.
7.1 Case Examples
Case 1. One-Stage Breast Augmentation (Fig. 21)
A 28-year-old nulliparous female desired increased breast
size. She was pleased with the overall shape. She dem-
onstrated relatively symmetric well-developed soft breasts
with no constrictions or severe density. She did not desire
breast implants. She was initially expanded with a BRAVA
handheld pump, for 10 h per day for 3 weeks. She was a
very compliant patient and her expansion proceeded well
over serial office visits. After 3 weeks of expansion she
underwent 400 cc of fat injected into each breast, har-
vested during liposuction of the thighs. At 6 months post
grafting her result is stable. Even in patients in whom lipo-
suction alone would not likely be entertained, it is possible
to obtain a sufficient amount of fat. This case also demon-
Fig. 21 Nulliparous patient with soft breasts and very good preoperative expansion. Postoperative views at bottom are at 6 months post grafting
157
strates that not all nulliparous patients expand poorly. The
anatomic compliance of the breast and the non-anatomic
compliance of the patient are equally vital to successful
pre-expansion.
Case 2. One-Stage Breast Augmentation: Multiparous
Patient (Fig. 22) A 45-year-old female who had two chil-
dren wished to increase breast volume. She had been pre-
viously pleased with her breast size and shape but had
undergone breast deflation which worsened after
childbearing.
The patient wore the BRAVA bra, using the higher pres-
sure hand pump, for 3 weeks preoperatively during the late
afternoon/early evening for approximately 8 h/day. This
patient used a manometer to quantify and follow the pre-
scribed negative pressures in her treatment programme.
After 3 weeks of expansion she had increased her breast vol-
ume by 250 % and underwent fat grafting with 600 cc of fat
injected into each breast. After 6 months, she demonstrated
significant volume increase and maintenance of volume.
Patients who have postpartum involution and mild ptosis can
often be improved with preferential fill in the lower pole and
158 D. Del Vecchio and R. Khouri

Fig. 22 Patient preoperative (left), preoperative grafting/postoperative expansion (centre) and 6 months after (right) fat grafting taken from
abdominal and thigh liposuction with 600 cc of fat grafted to each breast

Fig. 23 Constricted tuberous breasts can be augmented and reshaped, usually in two stages. All reshaping of the breast was performed using a
three-dimensional mesh release. The result below is 6 months after the second grafting session

release of the inframammary fold using a three-dimensional
mesh release.
Case 3. Two-Stage Breast Augmentation for Constricted
Tuberous Breasts (Fig. 23) A 28-year-old female with tuber-
ous breast deformity desired increased breast size and improved
shape. She had previously had a breast lift procedure with an
inverted-T incision and sub-areolar scoring to round out the
glandular shape. She did not desire breast implants. She was
initially expanded with a hand bulb operated pump, for 3 weeks
prior to her first fat grafting procedure where 300 cc of fat was
injected into each breast and she underwent three-dimensional
mesh release and peri-areolar scar revision.
After 4 months, she underwent a second round of
BRAVA pre-expansion, using a hand pump, and had a sec-
ond round of grafting with 300 cc of additional fat per
breast. Her results by photography and by MRI preopera-
tively and 8 months after her second procedure demonstrate
a significant increase in volume and in breast aesthetics
(Fig. 24).
Cosmetic Breast Augmentation with Fat Grafting
Fig. 24 (Left) Pre-expansion, MRI of patient in Case 3. (Right) MRI 6 months after second fat grafting. The final volume was read as being 345 cc
greater than preoperative in each breast; the patient received two grafting sessions of 300 cc each
8 The Future of Fat Grafting
to the Breast
Fat grafting is plastic surgery’s “disruptive technology”.
Like the stent changed the playing field for cardiac sur-
geons, plastic surgeons will face an influx of new “experts”
in the field of fat transplantation. While it may appear to be
a frustrating “land grab” in the marketplace, we are facing a
critical crossroads opportunity. As leaders in tissue trans-
plantation and in aesthetic breast surgery, we must focus our
positive energies on research and clinical collaboration to
define the role of this emerging technology for the safety of
our patients and for the viability of our specialty.
References
1. Fat Transfer/Fat Graft and Fat Injection, Findings of the ASPS Fat
Graft Task Force: Guiding Principles and Recommendations to the
Membership. Position Paper (2009)
2. Coleman SR, Saboeiro AP (2007) Fat grafting to the breast revis-
ited: safety and efficacy. Plast Reconstr Surg 119(3):775–785
3. Khouri R Follow-up presentation on BRAVA non surgical breast
expansion. ASAPS 2008 annual meeting, San Diego, CA
4. Del Vecchio D (2010) Breast augmentation with preoperative
expansion and mega volume fat grafting. American Association of
plastic surgeons 89th annual meeting, San Antonio Texas. March,
2010
5. Dolderer JH, Abberton KM, Thompson EW, Slavin JL, Stevens
GW, Penington AJ, Morrison WA (2007) Spontaneous large vol-
ume adipose tissue generation from a vascularized pedicled fat flap
inside a chamber space. Tissue Eng 13(4):673–681
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6. Peer LA (1950) Loss of weight and volume in human fat grafts:
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of liposuction cannula on adipocyte survival and the optimum tem-
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8. Shiffman M, Mirrafati S (2001) Fat transfer techniques: the effect
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Gilhar A (2005) Searching for the favorable donor site for fat
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14. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K,
Yoshimura K (2008) Influences of centrifugation on cells and
tissues in liposuction aspirates: optimized centrifugation for
lipotransfer and cell isolation. Plast Reconstr Surg 121(3):
1033–1041
15. Saxena V, Orgill D, Kohane I (2007) A set of genes previously impli-
cated in the hypoxia response might be an important modulator in the
rat ear tissue response to mechanical stretch. BMC Genomics 8:430
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(2004) Vacuum-assisted closure: microdeformations of wounds and
cell proliferation. Plast Reconstr Surg 114(5):1086–1096; Discussion
1097–1098
 Mastopexy Without Implants
Louis Benelli, Michele Pascone, and Charles Benelli
1 Introduction/History
The female breast has a high aesthetic value giving beauty
and harmony at the female corporal lines. The mammary
shape is an important point of the psychosocial well-being of
women. The breast is a strong symbol characterizing the
female identity. Modification of its shape can give aesthetic
corporal damage and eventually functional and psychological
alterations that can create difficulties in social relationships
and in self-image. The breast has a real beauty when it is
young, but generally loses its shape with the years, with varia-
tions of volume due to pregnancy or weight gain. The surgeon
should appreciate the motivation of the patient who has breast
ptosis not only as an aesthetic wish but overall like a necessity
to recover a sensation of corporal harmony and of sensuality.
The surgical correction of breast ptosis is a way to recuperate
the female identity and recover personal satisfaction.
The mastopex procedures are derived from reductive pro-
cedures, the only difference being that in pure ptosis no glan-
dular tissue is resected. Since the end of the nineteenth
century, when the first reductive procedures were described,
the different techniques evolved to be more effective and less
traumatic.
Pousson [1], Guinard [2], Morestin [3], Lexer [4], Kraske
[5], Thorek [6], Dartigues [7], Biesenberger [8], Gillies and
McIndoe [9], and Dufourmentel [10] have been pioneers in
breast plastic surgery, preparing to the birth of modern
techniques.
The safety of breast plastic surgery comes with the intro-
duction, by Schwarzmann in 1930 [11], of the concept of
L. Benelli, MD • C. Benelli, MD (*)
Plastic Reconstructive & Aesthetic Surgery, Hôpital Privé d’
Athis Mons, Athis Mons, France
e-mail: charles.benelli@yahoo.com
M. Pascone, MD
Dipartimento per le Applicazioni in Chirurgia delle Tecnologie
Innovative, Università di Bari, Bari, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_13
conservation of the deepithelized skin to improve the vascu-
lar support of the areola and so avoiding an areolar graft like
in the Thorek technique [6].
Another important progress is made by Strombeck in
1960 [12], with the introduction of the concept of dermo-
glandular flap. This new concept improves the blood supply
of the flap, the subcutaneous vascular connections between
skin and gland being conservated in the absence of big skin
undermining like in the Biesenberger technique [8, 13].
These concepts give good safety to mammaplast proce-
dures and open the gate to architectural improvement. The
Wise pattern [14] gave a clear preoperative vision of the
architectural remodeling permitted to popularize the
T-inverted incision reductive mammaplasties. Also, the
safer remodeling of the breast shape improves the aesthet-
ics of the shape. In the T-inverted techniques, different
pedicles and dermoglandular flaps architecture have been
described, giving great classic techniques such as Pitanguy
[15], Mc Kissock [16], Weiner and Aiache [17], and
Georgiade et al. [18].
Then, with adequate blood supply to gland, skin, and
nipple-areola complex; pleasant form and symmetry being
achieved; and preservation of the nipple sensation and the
gland’s lactation, the remaining problem was the scars’
length and their unpredictable quality.
So, trying to limit the scars, new techniques evolved
which created a unique vertical scar avoiding the horizontal
incision of the T-inverted techniques. Prudente [19] and Arie
[20] described a vertical procedure but the vertical scar
descended beneath the submammary crease. Later, Lassus
[21] proposed another vertical technique limiting the vertical
scar’s length using a resection “en bloc” of skin and glandu-
lar tissue so that the inferior extremity of the vertical scar
was not too much beneath beyond the submammary crease.
Ideally, searching to minimize the scar’s length, the
shorter scar is limited to the periareolar circle. First, peri-
areolar mastopexy was limited to very small breast ptosis,
owing to the high frequency of enlargement and distortion
caused by tension on the areola.
161
162
Fig. 1 Round Block cerclage stitch of 2-0 Mersilene passed with a long
straight needle. This stitch is passed in regular plane in the deep dermis
5 mm beyond the edge of deepidermization. This “Round Block” cer-
clage allows a good control of the areola and scar and can be used in
many aesthetic tumoral and reconstructive periareolar surgeries. Arrows
indicates the vector strength
Fig. 2 Cross-section view showing that the “Round Block” cerclage
stitch avoids tension on the areola and scar. Arrows indicates the vector
strength
To avoid the postoperative enlargement of areola and scar,
we introduced in 1988 [22] the use of a blocked circular
dermal suture passed in a purse-string fashion creating a
solid circular dermodermal scar block around the areola giv-
ing this procedure the name “Round Block” (Figs. 1 and 2).
The periareolar approach provides an easy access to the
whole gland, the “Round Block” giving the control of the
postoperative areolar diameter, and periareolar scarring
opens the gate to perform many breast surgeries like tumor-
ectomy, subcutaneous mastectomy, total mastectomy with
reconstruction, mastopexies with or without reduction or
augmentation, etc., thus extending the indication of periareo-
lar mastopexy to many cases of breast ptosis.
1.1 Concepts of the Different Techniques
In the short scar mastopexy, as circumvertical mastopexy or
T-inverted with short horizontal scar, the skin tension pro-
duces the breast shape. At the opposite, the concept of
periareolar mastopexy is that the shape is created by the
work inside of the breast, on the gland or by an implant. It is
L. Benelli et al.
necessary to separate the work on the gland to create the cone
shape from the work on the skin which must cover the gland
without any tension, using a “Round Block” to have a good
distribution of the skin on the glandular cone without tension
on the areola [22–24].
Most of the disappointing results of periareolar masto-
pexy are caused by the misunderstanding of this concept:
skin tension in a T-inverted or vertical technique gives a
conic shape, at the opposite in periareolar mastopexy skin
tension flattens the shape and gives periareolar healing
problems. The “Round Block” is not a technique to create
periareolar skin tension but a technique to ease the distribu-
tion of the skin on the preformed glandular cone reducing
tension on the areolar scar. An excessive periareolar skin
resection will create a skin tension closing the “Round
Block,” producing a flattened breast, enlarged scar and
areola.
2 Anatomy
The breast is a morphologic complex forming a relief from
which the adequate volume, the indefinable curve lines, and
the cover by a thin and uniform skin finish at the top with a
colored nipple and areola making a symmetric decor of real
beauty.
The breast pectoral relief is composed by a central part –
the mammary gland – from which the structure and the
development also depend from the peripheral part formed by
the integument that shapes and covers it: the skin with an
adequate thickness of fat.
The entire anatomy and physiology of the female breast is
programmed for feeding. The other periods than lactation
and breast feeding are periods in which the glandular tissue
prepares itself to be ready for breast feeding, growing at
every periodical cycle and finally involuting apart from preg-
nancy periods and after menopause.
On the breast we distinguish the thin and elastic periareo-
lar skin from the strong thick skin of the breast basis and the
submammary crease. The function of the thin and elastic
periareolar skin is to adapt itself to the breast volume
changes, which generally produce fine scars, and is easily
stretched by the weight of the gland. The function of the
strong thick skin of the breast basis and the submammary
crease is to support the breast, and the scars it produces are
potentially much larger.
For support of the breast, the interest of the periareolar
technique is to remove the thin and elastic stretched skin
around the areola, which does not have any supportive value,
and to conserve the thick skin at the base of the breast and
submammary crease.
Mastopexy Without Implants
3 Authors’ Preferred Technique:
The Periareolar “Round Block”
Technique
3.1 Surgical Technique
3.1.1 Step 1: Planning and Marking
We have no standard pattern; each pattern is specific to the
individual patient. The marking begins with the patient
standing, then lying supine, and finally back in the standing
position.
Marking in the Standing Position
The midline is marked to maintain symmetry. The breast
meridian is marked at the beginning on the clavicle, 6 cm
from the midline. The meridian is not the meridian of the
ptotic breast, but the meridian of the manually reshaped
breast. This new meridian will not necessarily cross the ptotic
nipple because the mammary ptosis is generally a lateraliza-
tion of the breast due to chest wall convexity (Fig. 3a and b).
The new meridian is often more medial than the one of the
ptotic breast. The lower part of the breast meridian is not marked
while the patient is standing but while she is lying supine.
The New Areola Vertical Position
The superior border of the areola (point A) is marked like
in a Pitanguy technique on the breast meridian, 2 cm
higher than the anterior projection of the submammary
crease. Reshaping the breast manually, the surgeon veri-
fies that point A is marked in the correct position.
a b
Fig. 3 Skin marking. Select the four cardinal
points to reduce the ellipse size to its
minimum. You will need a large amount of
skin to cover the glandular cone, and the skin
will retract after surgery. Any skin over
resection can produce serious complications
163
Contralateral point A is marked by measuring the distance
to the sternal notch.
Symmetry
For a more precise evaluation, the surgeon observes the
patient standing in the anatomic position. The best position
for the observer is facing the patient at a minimum of 3–6 ft.
In case of volume asymmetry, this preoperative evalua-
tion in the standing position is useful for estimating the pos-
sible variation in reduction weight from one side to the other.
Marking the Patient Who Is Lying Supine
The lower part of the marking is done with the patient lying
supine, with the arms lying symmetrically at the patient’s
sides.
Marking of the Submammary Crease and Gland Limits
Point S is the point where the breast meridian crosses the
submammary crease. It usually crosses the crease roughly
10 cm from the midline.
Point B is the inferior border of the new areola. It is
marked on the breast meridian, and its position is determined
by the estimated final breast volume to be covered and by the
potential for the breast skin to retract. The distance between
point B and point S (BS) may vary from 5 to 12 cm.
Leaving an Ample Distance BS Has Two Advantages
Covering the glandular cone without skin tension prevents
flattening of the breast shape, allowing the skin to retract in a
more natural adaptation to the height of the new glandular
164 L. Benelli et al.

cone obtained by internal shaping of the gland. Reducing the

size of the excised skin facilitates better skin adaptation to
the final size of the areola during periareolar skin suturing.
Points C and D are the lateral and medial limits of the
ellipse, respectively. These points are marked symmetri-
cally, regarding the breast meridian as a guide and aiming to
mark the minimal size of the ellipse because ample skin is
needed to cover, without tension, the new glandular cone,
lifted and projected earlier. For this reason, point C, the lat-
eral limit of the ellipse, usually is near the lateral border of
the areola (Fig. 3b).
The medial limit of the ellipse (point D) is symmetrical to
point C, using the breast meridian as a guide, and located
8–12 cm from the midline following the width of the chest
wall. The medial border of the contralateral ellipse is marked
symmetrically referring to the midline.
Checking the markings is performed by pinching together
A and B, then C and D, in order to verify that the remaining
skin will be adequate to cover the glandular cone without
tension. Finally, the ellipse is marked with a dotted line that
joins points A, B, C, and D. At this point, the ellipse shape
should be almost round when the patient is lying supine.
A final check of the ellipse design is done with the patient
standing. Gravity gives a vertical shape to the ellipse. The
surgeon should check for symmetry and note and photograph
the measurement of the marking.

3.1.2 Step 2: Preparation Fig. 4 Deepidermization. The periareolar epidermis can be removed
With the patient sitting partly upright, the arms are affixed quickly by simple traction of a concentric epidermal flap
to the body using adhesive bands around the thighs. The
region is infiltrated with a dilution of physiologic saline
(1,000 ml) and epinephrine (1 mg). The area that will be
detached is subcutaneously infiltrated, except for the ellipse
and surrounding 3 cm, in order to preserve the vasculariza-
tion of the skin edges. The prepectoral space is also
infiltrated.

3.1.3 Step 3: Incision and Dissection

Deepithelialization of the periareolar ellipse is performed by
pulling on a concentric epidermal flap (Fig. 4). The areola is
marked with a “cookie cutter” on the tensed skin at 1.5 cm
diameter more than the desired final diameter to compensate
for a stretching and retracting afterward. Usually cut at
5.5 cm to close at 4 cm.
An incision on the deepithelialized dermis is made from 2
to 10 o’clock, at 1 cm inside of the skin edge to improve the
subdermal vascular support of the epidermal edge.
Subcutaneous dissection is performed with consideration
for the blood supply to the skin. Dissection extends from the Fig. 5 The cutaneoglandular detachment respects the subdermic vas-
ellipse to the submammary crease limits (Fig. 5). cularization and is extended to facilitate an even skin distribution on the
new glandular cone. (A) Pitanguy technique. 2 cm higher than anterior
At this stage, the surgeon incises the gland in order to projection of the submammary crease. (B) Inferior border, (C) lateral
constitute the dermoglandular flap that will be supporting the border, (D) medial border
Mastopexy Without Implants
superior flap
keel-like
lateral resection
flap
medial
flap
keel-like
resection keel-like resection
Fig. 6 The cut of the glandular flaps, and, if necessary, their reduction,
is similar to those used in a T-inverted technique: a vertical dermoglan-
dular superiorly based flap supporting the NAC, a lateral and medial
glandular pillar, and a skin flap
areola. This incision does not follow the edge of the dermis
because it is often too near the areola, especially on the lat-
eral side.
The glandular incision is semicircular at 3 cm from the
inferior areola’s edge in order to preserve innervation and
blood supply to the areola. This incision facilitates opening
the prepectoral space, which we dissect only in the avascular
central space, preserving the peripheral blood supply, where
the breast is more adherent to the fascia and where the perfo-
rators are located. The inferior glandular flap is then elevated
between two clamps and cut vertically beyond the breast
meridian up to the fascia.
As a result of this dissection, four flaps will have been
created (Fig. 6):
• A superior dermoglandular flap supporting the areola
• A glandular medial flap
• A glandular lateral flap
• The detached skin flap
If necessary, work on the glandular flaps will facilitate a
reduction in volume by reshaping the breast via fixation of the
flaps in a new position, forming a glandular cone on which the
skin will be redraped with the “Round Block” closing.
3.1.4 Step 4: Resection of Gland Following
the Wise Pattern
Depending on the case, resection can be executed on the dif-
ferent glandular flaps to get volume symmetry on the two
165
sides. To reduce the upper pole, a Pitanguy keel-like resec-
tion can be performed (Fig. 6). To reduce the lateral lower
pole, resection on the lateral flap is performed as for a
T-inverted reduction following the Wise pattern (Fig. 6). If
the lateral flap remains too thick, the reduction can be
extended to the posterior side of the flap in the prepectoral
space to obtain the desired thickness.
To reduce the medial lower pole, the resection can be
extended to the posterior side of the flap in the prepectoral
space to obtain the desired thickness.
To reduce the medial lower pole, the resection can be per-
formed on the distal part of the medial flap. If the volume to
resect is large, the resection can be performed with a
T-inverted technique. In other cases, the medial flap reduc-
tion is not extended medially in order to leave the necessary
volume to refill the inner pole of the breast.
3.1.5 Step 5: Glandular Modeling
Depending on the anatomy of each patient, the glandular
flaps are situated to achieve a nice shape with minimal
detachment to prevent fat necrosis.
The glandular flaps are assembled in order to reduce the
base of the breast, providing a conical shape and the best
long-term support. The criss-cross mastopexy often works
well to accomplish these goals.
We begin reducing the upper base of the breast using a
plication of the upper pole.
The lower base of the breast is reduced by crossing the
two lower glandular flaps (lateral and medial). The flap that
is crossed over the other has the biggest amplitude of trans-
lation. Because ptosis involves a sagging of the breast, but
also generally a lateralization of it, we generally prefer
crossing the lateral flap over the medial one to medialize
the breast shape. In the rare cases in which we desire to
lateralize the breast, we cross the medial flap over the lat-
eral one.
In most cases, we begin the criss-cross mastopexy by
rotating and folding the medial flap behind the areola, fix-
ing its distal part to the pectoralis muscle using a U point
(Fig. 7). The lateral flap is crossed over and fixed to the
medial flap by additional U points (Fig. 8). These glandular
stitches don’t squeeze the glandular tissue to create glandu-
lar cytosteatonecrosis. Moving these flaps reduces the base
of the breast and creates a glandular cone on which we
place the areola.
3.1.6 Step 6: The Dermal Window for Areola
Fixation
Fixation of the areola to the superior border of the ellipse is
facilitated by a dermal window that we open with a 1 cm
166
lateral flap medial flap
Fig. 7 Medial flap rotation and fixation using a mattress suture on the
pectoralis
Fig. 8 The lateral flap is crossed over the medial flap, and the crossing
line is sutured using some superficial U points, grasping the Cooper’s
ligaments to prevent any constriction of the flap vascularization. Strong
support of the new conic shape will be achieved after full breast lacing
(Step 7)
incision of the dermis (Fig. 9), 5 mm from the edge. Through
this window we create a little intraglandular pocket in which
we will lift and suture the supraareolar dermis to the deep
dermis of the pocket. This fixation supports the areola with-
out tension on the skin edge.
L. Benelli et al.
Fig. 9 The dermal window prevents enlargement of the scar by strong
fixation of the areola’s superior border through the window and allows
the surgeon to bury the “Round Block” cerclage knot
Fig. 10 Full breast lacing strongly supports the conical shape by using
large inverted stitches of Mersilene 2/0. The first stitch is transareolar
and allows control of the NAC anterior projection. All these stitches are
tied without any tension
3.1.7 Step 7: The Full Breast Lacing
Optimally, the glandular cone will be well shaped, with the
areola at the top of the cone. The quality of the tissue deter-
mines whether this result can be maintained at long term. To
provide the best support of the shape, we prefer to use full
breast lacing of braided polyester mersilene 2/0 applied with
a long straight needle (Fig. 10). This type of lacing is useful
in case of poor-quality glandular tissue, especially in patients
with adipose involution.
This lacing is performed by using some large inverted
stitches, with moderate tension traversing the entire thick-
ness of the breast diameter to maintain crossing of the
Mastopexy Without Implants 167

Fig. 11 View of the long straight needle passing in regular plane in the
deep dermis 5 mm beyond the ellipse edge

glandular flaps. This lacing, at its superior part, also

passes through the areolar dermoglandular flap. This pas-
sage allows control of the anterior projection of the nip-
ple-areola complex and prevents any protrusion of it. It is Fig. 12 The “Round Block” inside of the ellipse with a Mersilene 2/0
is passed with curved needle like a purse string going alternatively in
important that these full breast lacing stitches be applied and out of the dermis at 2 mm from the edge of the deepidermized area
without tension to avoid strangulating the gland and creat- inside of the ellipse
ing fat necrosis. The role of the full breast lacing is to
provide passive support of the conical shape obtained by
the superficial stitches of the glandular modeling (see
Step 5).

3.1.8 Step 8: “Round Block” Cerclage Stitch

The detached skin is redraped on the glandular cone, and
complementary detachment may be necessary to free some
skin in order to obtain an easy elevation and even distribution
of the skin all around the areola.
The “Round Block” cerclage stitch can be placed in two
manners: outside of the ellipse or inside of the ellipse.

“Round Block” Outside of the Ellipse

The “Round Block” cerclarge stitch is passed like a purse
string in the deep dermis 5 mm beyond the edge of the ellipse
(Fig. 11). The suture begins through the dermal window over
the suture fixing the areola, follows a regular plane in the
deep dermis, and finishes as its starting point (Fig. 1). We use
mersilene 2/0 applied with a 7-cm long straight needle,
allowing a regular plane in the dermis.
“Round Block” Inside of the Ellipse
The “Round Block” cerclage stitch of Mersilene 2/0 is
passed with a curved needle like a purse string going alterna-
tively in and out of the dermis at 2 mm from the edge of the
deepithelialized area inside of the ellipse (Fig. 12).
Pulling on the suture elevates all the detached skin around
the areola; a sliding of the skin on the stitch allows an even
Fig. 13 The “Round Block” cerclage stitch is pulled and tied onto a
cookie cutter, facilitating exact measurement and symmetry of the
diameter of the two areolas
distribution of the pleats. To close with symmetry of the
areolar diameters, we measure the diameter with a ruler or
we can also use a cookie cutter of the desired diameter
inserted and the suture tied onto it (Fig. 13) as described by
Robles [25] and Fournier [26]. The knot is buried behind the
skin through the dermal window. We prefer a braided polyes-
ter suture like the mersilene 2/0 because the scar penetrates
the fiber of the stitch, avoiding a sliding of the skin on the
suture when moving the breast. Before applying the suture,
168
Fig. 14 The “Round Block” allows the surgeon to lift and drape the
detached skin over the reshaped glandular cone with an even distribu-
tion of the skin excess
Fig. 15 The second dermoareolar Round Block is put in place after the
first Round Block and will help to achieve an even distribution of the
periareolar skin excess to be adapted and fixed to the areola on eight
points: the four cardinal points and four points between each of them
we improve the distribution of the pleats around the areola.
We avoid deep pleats. Instead, we try to have more numerous
superficial pleats. This is more a compression than a plica-
tion of the skin excess. The “Round Block” allows the eleva-
tion and the even distribution of the skin flap over the new
glandular cone (Fig. 14).
3.1.9 Step 9: A Second Dermoareolar “Round
Block” Taking the Retroareolar Tissue
This second dermoareolar “Round Block” (Fig. 15) will help
to create an even distribution of periareolar skin excess and
the resulting pleats to be adapted and fixed to the areola on
L. Benelli et al.
eight points that are the four cardinal points and four points
between each of them.
This second “Round Block” is done with a clear nylon
monofilament 4/0 on curved needle. It starts at 6 o’clock in the
retroareolar tissue and continues by taking the crest of the der-
mic pleats inside of the closed ellipse at 3 mm inside of the
periareolar skin edge, and taking again the retroareolar tissue
when arriving at the level of the next of the eight areolar points.
This second “Round Block” has different goals:
• To help the final skin compensation suture by the even
distribution of the pleats around the areola
• To bury the dermis and the fat protruding between the
areola and the first “Round Block”
• To begin to control the nipple-areola complex anterior pro-
jection, avoiding protrusion through the first “Round Block”
• To close the wound and allow and aspiration drainage
before finishing the final skin compensation suture
3.1.10 Step 10: Regulation of Areola Projection
The conization of the gland gives a strong anterior projec-
tion to the nipple-areola complex, sometimes generating its
protrusion.
We propose some specific sutures to control the anterior
projection of the nipple-areola complex:
• The full breast lacing transareolar first stitch (Fig. 10) is
the first control of the nipple-areola complex anterior pro-
jection, performed after glandular modeling (Step 7).
• Inverted dermoareolar stitches take a large vertical grip in
the areola’s thickness and a large horizontal grip in the
edge of the dermal ellipse. The location of these stitches
is also useful for an even distribution of the skin excess
(like Cardinal stitches) (Fig. 16).
• Diametrical transareolar U points are passed with 2/0
braided polyester using a straight needle. In order to cover
the knot, the suture begins and finishes buried behind the
areola (Fig. 17). This U point is also useful to give a cir-
cular shape to the areola; in some cases the areola tends to
take on an oval form. This diametrical U point is put in
place in the great diameter of the oval areola. A little ten-
sion on the stitch gives a circular shape to the areola.
• The second internal dermoareolar “Round Block” suture
described in Step 9 is also very useful to control the
nipple-areola complex projection.
All these types of stitches and sutures allow control of the
size, shape, and projection of the nipple-areola complex.
3.1.11 Step 11: The Skin Closure
Accommodation of the big ellipse to the small areola requires
a compensation suture (Fig. 18):
Mastopexy Without Implants
Fig. 16 Inverted dermoareolar stitches facilitate control after the areo-
la’s protrusion through the “Round Block” cerclage. Arrows indicates
the vector strength
Fig. 17 Diametric transareolar points constitute a barrier preventing
the areola’s protrusion and giving a circular shape to the areola when it
has tendency to be ovoid
Fig. 18 Intradermic compensation suture using a Monocryl 4/0 taking
a large horizontal bite on the ellipse edge and a vertical grip on the
areola’s edge
• Continuous intradermic compensation sutures using intra-
dermal a Monocryl 4/0 starting at the top of the areola, tak-
ing a large horizontal bite on the edge of the ellipse and a
169
vertical bite on the edge of the areola. This suture is per-
formed to avoid creating deep pleats but to have an even
distribution of superficial pleats. The suture is totally intra-
dermal and the starting and finishing knots are buried not to
leave any marks on the skin; the suture will resorb by itself.
• Compensation suture by separated points will take an
external small grip in U of the areola supporting the knot
and large intradermal grip in the edge of the ellipse. This
suture by separated points has advantage of facilitating an
even accommodation of the skin excess around the areola
but has the disadvantage of leaving marks of the knots on
the areolar skin.
3.1.12 Step 12: The Dressing
and Postoperative Care
The first dressing is a wet compress on the areola and dry
compresses on the detached skin. They are maintained with
an adhesive bandage of moderate compression to prevent
hematoma formation. Vacuum drainage exits below the axilla.
The second day after surgery, the patient leaves the clinic.
The vacuum drainage and all the dressings are usually
removed. We check the vitality of the flaps and clean the skin
with antiseptic solution and later with ether to facilitate the
adhesion of an adhesive pad. This is a sterile, ultrathin, highly
conformable, semiocclusive polyurethane foam adhesive pad.
This dressing covers the areola and scar and maintains the
detached skin. The patient leaves the clinic wearing a simple
brassiere that maintains the breast and the adhesive pad.
This adhesive polyurethane foam pad has many advantages:
• Prevents tension on the scar
• Absorbs exudate
• Protects against trauma and bacteria
• Controls nipple-areola anterior projection during the
swelling period
• Allows the patient to take showers without changing the
dressings
• Is simple for the patient, who does not have to remove the
dressing and who will only have to visit the office for a
weekly control and change of the adhesive pad
The patient must wear a brassiere night and day for 2 months.
3.2 Complications and How to Avoid Them
The same complications are those occasioned by the tradi-
tional mammoplasty (Table 1).
Cutaneoglandular detachment eases the problems of cuta-
neous necrosis and glandular cytosteatonecrosis. To avoid
those complications, some precautionary measures must be
observed.
170 L. Benelli et al.

Table 1 Complications in 581 cases The first assembling stitches of the criss-cross mastopexy
Hematoma 10 1.7 % should be superficial to avoid strangulation of the flaps. The
Seroma 5 0.9 % full breast lacing stitches extend through the thickness of the
Infection 3 0.5 % reshaped glandular cone and are set without any tension. Their
Cytosteatonecrosis 11 1.9 % only role is one of passive contention of the mammary cone.
Areola necrosis 0 –
Areola sensitivity loss 0 –
Skin flap partial necrosis 7 1.2 % 3.5 Long-Term Problems
Hypertrophic scar 2 0.3 %
Scar and areola enlargement are prevented via minimal peri-
areolar skin resection, the correct use of the “Round Block”
3.3 For Good Cutaneous Vascularization cerclage stitch (see Step 8), and the anchoring of the areola
through the dermal window (see Step 6).
• Avoid tension by resecting as little skin as possible Flattening of the shape and ptosis recurrence are pre-
• Do not infiltrate the edge of the deepithelialized ellipse vented by good criss-cross mastopexy or glandular plica-
• During subcutaneous dissection, preserve subdermal tion invagination maintained by the full breast lacing (see
vascularization Steps 5 and 7).
• Restrict the subcutaneous detachment to its sufficient The persistence of pleats is avoided by passing the “Round
minimum Block” cerclage stitch in a regular plane inside the deep der-
• Delicately manipulate the flap by only pinching the deepi- mis, by even distribution of the skin excess all around the
thelialized dermis margin areola, by making the skin slide over the “Round Block” cer-
clage stitch (see Step 8), and by applying a final intradermal
compensation suture (see Step 10).
3.4 For Good Glandular Vascularization Protrusion of the areola is prevented in the following
cases by the use of different sutures that can be associated or
• Do not infiltrate the glandular flap basis used separately:
• Restrict the subcutaneous and prepectoral detachment to its
sufficient minimum to allow the necessary glandular mobi- • Transareolar full breast lacing first stitch (Fig. 10)
lization and to reduce and reshape the mammary cone • Second dermoareolar “Round Block” (Fig. 15)
• Execute volume reduction over the distal parts of the flaps • Inverted dermoareolar stitches (Fig. 16)
to limit their length • Transareolar diametrical U points (Fig. 17)
Mastopexy Without Implants 171

Clinical Case (Round Block)

a b c

d e f

(a–c) preoperative, (d–f) one year postoperative

172
4 Other Techniques
The periareolar “Round Block” technique is a good choice
for little or moderate ptosis with good quality of gland and
skin. But in cases of poor anatomic conditions due to large
skin excess and poor quality of glandular tissue we will need
to consider a vertical mastopexy (Fig. 19a, b) to the periareo-
lar mastopexy [20] and in case of very redundant skin excess
such as massive weight loss it can be necessary to excise
more skin doing a “J” scar (Fig. 20a, b) or a T-inverted scar
with a short horizontal skin excision in the submammary
crease (Fig. 21a, b) [27, 28].
4.1 Concept of the Association
of Periareolar and Vertical Skin Excision
The association of a periareolar and a triangular vertical skin
reduction will allow the usual inconveniences of the vertical
techniques and periareolar techniques to diminish. Indeed
the geometrical study of the breast cone, as studied by Arion
[29], shows that every vertical skin resection following the
generating line of the cone will increase its projection. On
the opposite, every horizontal skin resection following the
directrix curve of the cone will decrease its projection.
A vertical skin resection will create two dog ears: one supe-
riorly, which is useful giving the projection of the nipple-areola
complex, and one inferiorly, which is unaesthetic and may
require a short horizontal scar or a longer vertical scar with the
inconvenience that the scar goes beyond the submammary fold.
The periareolar skin reduction by a “Round Block” will allow
a list of the inferior breast skin excess and so eliminate the
inferior dog ear, avoiding a short horizontal skin excision in the
submammary fold. This periareolar inferior breast skin lift also
reduces the length of the vertical scar and allows a decrease of
usual horizontal pleats along the vertical scar.
The triangular vertical skin excision under the periareolar
ellipse avoids some inconveniences of the periareolar masto-
pexy and
Fig. 19 (a) Peroperative skin plication to adapt the
skin on the glandular cone with a moderate tension on
a vertical scar. Temporary mark stitches are put in
place. (b) Deepithelialization of the marked triangular
area. 1, 2, 3 indicates the suture placement
L. Benelli et al.
• Decreases the ellipse circumference and so decreases the
postoperative periareolar pleats
• Gives more breast shape anterior projection
• Gives an inferior strong vertical fibrous dermo-dermic
scar on the breast meridian that will better sustain the
breast shape in the late postoperative phase
4.2 The Circumvertical Technique’s
Description
4.2.1 Marking
The marking of the periareolar ellipse is made in the same
manner described in the Round Block technique (Step 1).
The marking of the inferior triangular skin reduction under
the periareolar skin reduction is made by pushing the breast
skin alternatively laterally and medially marking the mobi-
lized skin on the breast meridian. It will give a first evalua-
tion of the vertical triangular skin excess, but will not be cut
at the beginning of the procedure but only after the criss-
crossed glandular reshaping by the periareolar approach.
4.2.2 Glandular Reshaping
The glandular reshaping will be made by a criss-cross mas-
topexy with a vertical superiorly based dermoglandular flap
which supports the nipple-areola complex as previously
described precedently (Step 5).
4.2.3 Triangular Vertical Skin
Deepithelialization (Fig. 19a)
Before excision in order to safely evaluate the excess skin
that is to be removed some stitches are put in place following
the Lassus technique [19]. When appropriate skin draping is
obtained (Fig. 19b), marking is achieved to allow the final
skin closure in the same position. The marked triangle is
deepithelialized in order to preserve the subdermic vascular-
ization of the skin flaps and to conserve the support of the
strong vertical dermic plication.
Mastopexy Without Implants
Fig. 20 (a) Peroperative skin plication to adapt the skin on the glandu-
lar cone with a moderate tension on a J scar. Temporary mark stitches
are put in place. (b) Deepidermization of the marked area. 1, 2, 3, 4
indicates the suture placement
4.2.4 Periareolar Skin Closure
The periareolar skin closure is made by a Round Block as
described previously (Steps 8 and 9). The vertical scar is
closed by inverted stitches lifting the skin excess on the glan-
dular cone and with an intradermic running suture.
4.2.5 Technique in J or in T Inverted
When the skin excess is very abundant, like after massive
weight loss, it can be useful to decrease the length of the
173
Fig. 21 (a) Peroperative skin plication to adapt the skin on the glandu-
lar cone with a moderate tension on a T-inverted scar. Temporary mark
stitches are put in place. (b) Deepidermization of the marked area. 1, 2,
3, 4 indicates the suture placement
vertical scar by adding a horizontal skin excision with a J
scar (Fig. 20a, b) or a T-inverted scar (Fig. 1a, b).
The procedure is exactly the same for a circumvertical
excision except that the design of the deepithelialized area is
extended to the submammary crease.
When a T-inverted scar is needed, we like to use a supe-
rior pedicle mastoplasty, as described in the chapter
“Tuberous breast: Different morphological type and corre-
sponding correction flaps”.
174 L. Benelli et al.

Clinical Case (Circumvertical technique)

a b

c d

e f g

h i j

(a) Preoperative markings, (b) flap supporting nipple areola complex and pillars, (c) vertical scar intraoperatively, (d) vertical scar 3 months
postoperative, (e–g) preoperative, (h–j) 3 months postoperative
Mastopexy Without Implants
5 Pearls and Pitfalls
Pearls
The Round Block suture avoids postoperative enlarge-
ment of areola and scar, and allows treatment of many
cases of ptosis with a single periareolar scar.
The concept of periareolar mastopexy is that it is
necessary to separate the work on the gland to create
the cone shape from the work on the skin which must
cover the gland without any tension.
The abundance of dermo-dermic adhesions of the
deepithelialized skin gives safety to the flap and long-
term shape support.
The periareolar skin reduction by a “Round Block”
will allow reduction in length of the vertical scar.
Pitfalls
Excessive periareolar skin excision gives skin tension
and so will produce a flattening of the shape and heal-
ing problems.
Just after the Round Block suture, equilibrating the
pleats by sliding the skin on the Round Block stitch
avoids the accumulation of deep pleats in the same place.
Avoid glandular cytosteatonecrosis by creating
glandular flaps following the direction of the main vas-
cular pedicles (lateral and internal thoracic arteries)
and anchoring these flaps without squeezing them with
deep sutures on tension.
Conclusion
These “Round Block” techniques permit us to treat various
types of breast morphology, giving a great importance to
patient selection in choosing each surgical option. Our
main criterion has been the safety of the procedure for pres-
ervation of vitality, function, and sensitivity of the tissues.
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2. Guinard M (1903) Comment on: Rapport de l’ablation esthétique des
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3. Morestin H (1907) Hypertrophie mammaire traitée par la résection
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transposition in subcutaneous mastectomy, reduction mammaplsty
and mastopexy. Plast Reconstr Surg 51:115
18. Georgiade NG, Serafin D, Morris R, Georgiade G (1979) Reduction
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Plast Surg 3:211
19. Prudente A (1936) Contribuiçao ao Estudo da Plástica Mamária
Cirurgia Estética dos Seios. Ed. Publicistas, São Paulo
20. Arie G (1957) Una nueva tecnica de mastoplastia. Rev Latinoam
Cit Plast 3:23
21. Lassus C (1970) A technique for breast reduction. Int Surg 53:69
22. Benelli L (1988) Technique de plastie mammaire le “Round Block”.
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23. Benelli L (1990) A new periareolar mammaplasty: the “round
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24. Benelli L (1991) Technique personnelle de plastie mammaire
périaréolaire: le “Round Block”. Cahiers de Chirurgie 77:15–25
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cale. Masson, Paris
 Mastopexy with Implants
Francesco Stagno D’Alcontres, Flavia Lupo,
Gabriele Delia, and Michele R. Colonna
1 Introduction
Breast ptosis occurs as a physiological downward disloca-
tion of the breast as an effect of pregnancy and lactation in
young women, or as a postmenopausal reduction of estrogen
in the elderly. Certain medications, weight gain or loss, and
genetic predisposition can also contribute to the develop-
ment of ptosis.
In 1956, when Dufourmentel and Mouly [1] described the
first classification of ptosis, breast ptosis was identified as
the downward dislocation of the nipple-areolar complex
(NAC), provided its normal position lay on the intersection
between a transverse line directed through the mid-point of
the arm and a vertical line lying two finger-widths from the
sternoclavicular joint. Afterward, Lalardrie and Jouglard [2]
pointed out the importance of the descent of the lower pole
with respect to the inframammary fold (IMF). Two years
later, Regnault [3] assessed NAC dislocation with respect to
the IMF and a new classification was created:
• Minor ptosis: NAC at the same level as, or no lower than
5 cm below, the IMF
• Moderate ptosis: NAC 5–10 cm below the IMF, but not
inferior to the lower breast margin
• Severe ptosis: gland dislocated below the IMF, and NAC
positioned more than 10 cm below the IMF and pointing
downward
• Glandular ptosis: NAC in its normal position but the gland
lower than the IMF
F. Stagno D’Alcontres, MD (*) • F. Lupo, MD • G. Delia, MD
M.R. Colonna
Dipartimento di Specialità Chirurgiche,
Università di Messina, Azienda Ospedaliera Universitaria
“G. Martino”, Messina, Italy
e-mail: fdalcontres@gmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_14
• False ptosis or pseudoptosis: gland hypertrophy and
downward dislocation of the lower breast pole with the
NAC in a normal position
Subsequently, Bostwick [4] proposed a mixed classifica-
tion regarding NAC position with respect to the IMF but
added skin quality as a new parameter.
We believe the 2006 classification [5] by Spear, compris-
ing minor, moderate, and severe ptosis, pseudoptosis, and
parenchymal distribution, is the most fitting (Fig. 1).
2 Surgical Techniques
Several elements should be taken into consideration for opti-
mal surgical planning. These include the patient’s age, his-
tory of pregnancy and/or breast feeding, history of previous
breast surgery (including liposuction), distribution of fat and
parenchymal components of the breast, NAC position, skin
quality, base diameter of the gland, symmetry, and presence
of congenital deformities.
We believe that the specific indication for ptosis correction
plays a critical role in defining the best surgical technique; as
pointed out by Botti [6], the final goal is to restore the most
natural size, which is achieved by adding the needed volume
through implant insertion. Implant pocket selection is deter-
mined by the surgeon and can be subglandular (retromam-
mary), retropectoral, or dual plane (partial retropectoral).
As is pointed out by Tebbetts [7] and Hammond [8], glan-
dular ptotic breasts offer unique challenges that often require
a combined technique. In these cases we use subglandular
and partial retropectoral approaches in a dual plane, ensuring
adequate soft-tissue coverage of the implant and optimizing
implant–soft-tissue dynamics to lower contracture rates
while maintaining the benefits of muscular manipulation.
The choice of the implant and implant features (type, vol-
ume, projection, anatomical position) should be determined
177
178
Fig. 1 Classification of breast
ptosis (Adapted from Spear [31])
Fig. 2 Hemiperiareolar pattern
on the basis of a careful physical examination and attention
to the patient’s demands.
The implant should have an adequate size: in fact, to cor-
rectly expand the dissection pocket anteriorly it should have
adequate projection, and should be wide enough to expand
the pocket both medially and laterally. To meet these criteria
larger implants are often required, about which patients
should be appropriately counseled preoperatively.
Special considerations must be taken into account regard-
ing the relationships between the gland and the pectoralis
major. Tebbetts [7] stressed the importance of maximizing
contact of the anterior surface of the implant with the poste-
rior surface of the parenchyma in cases of correction of glan-
dular ptosis using an implant. This degree of contact has
been proved to allow an implant of adequate width and pro-
jection to expand the lower breast envelope in all directions.
Glandular ptosis in a thin patient (less than 2-cm pinch
thickness superior to the parenchyma) presents the most dif-
ficult case scenario. A simple retromammary augmentation
in these patients could produce a visible implant edge or
F. Stagno D’Alcontres et al.
Fig. 3 Circumareolar pattern
traction rippling superiorly or medially. Tebbetts proposed a
type III dual plane approach, by dividing the pectoralis ori-
gins inferiorly and freeing the parenchyma–muscle interface
up to approximately the superior border of the areola.
Finally, a larger mass of breast parenchyma and weak
attachments to the pectoralis at the parenchyma–muscle
interface produce a greater stretching force that transmits to
both the parenchyma and the lower pole skin envelope,
which leads to increased distance from the nipple or inferior
border of the areola to the inframammary fold.
3 Indications
The authors agree with Tebbetts [7] that when the distance
from the areola to the inframammary fold is 7 cm or less
under maximal stretch, the ptosis can be corrected by an
appropriate implant alone, without mastopexy, through the
use of a dual plane technique. The implant is placed through
a hemi-periareolar or circumareolar access (Figs. 2 and 3).
Mastopexy with Implants
Fig. 4 Circumareolar pattern with little wedge vertical excision
When skin excess also needs to be treated, both a
circumareolar and a vertical scar will be required to achieve
optimal NAC repositioning. These cases also require implant
placement to maximize outcomes (Fig. 4).
Severe ptosis is often best addressed with a minor breast
reduction for better NAC repositioning, gland remodeling,
and removal of both gland and skin excess (Fig. 5). An
implant can also be inserted in patients requesting volume
augmentation, as is seen in the majority of cases.
4 Authors’ Preferred Technique
For minor corrections, we prefer to treat patients under a
combination of sedation and local anesthesia; severe and
difficult cases are treated under general anesthesia.
4.1 Hemi-periareolar or Circumareolar
Access Together with Breast Implant
Insertion
Indications: Mild to moderate (first- and second-degree)
ptosis without significant skin excess (Fig. 6a–d).
Preoperative planning and marking are performed with
the patient in the upright position. Preoperative marking
includes the following landmarks: the chest midline from the
suprasternal notch to the xiphoid process, the IMF, and the
breast meridian, and the new nipple position. The new nipple
position and the planned superior aspect of the new areola lie
on the meridian. Medially and laterally, two lines are drawn
179
Fig. 5 Circumareolar pattern with larger vertical excision
on the areolar side; inferiorly, pinching the skin should sug-
gest how much skin is to be conserved, while marking the
skin below the areolar margin. An ellipsoidal pattern is then
obtained around the areola [11].
A dual plane approach is the first option in cases of minor
skin excess, whereby the lower border of the areola is incised
from 4- to 8-o’clock (hemi-periareolar), while a circumareo-
lar approach is preferred in cases with greater excess of skin.
De-epithelialization and excess skin removal may be car-
ried out now or after dual plane pocket dissection, keeping in
mind that increased projection will subsequently be achieved
by the implant; conservative skin resection should be per-
formed initially, and can be eventually completed after the
implant is placed [8–15].
The breast parenchyma is subsequently dissected
obliquely to the lateral pectoralis major border, and the sub-
glandular portion of dissection (almost 20 % of the total
pocket amount) is completed, keeping the inferior flap thick
enough to cover the implant and taking care to preserve
nipple innervation from the fourth and fifth anterolateral
branches.
The dissection proceeds, either bluntly or with electro-
cautery, and the inferior border of the pectoralis major is
opened, disinserting the lower 2–3 cm of its medial margin.
The submuscular part of the pocket is then undermined supe-
riorly, medially, and laterally, leaving the pectoralis minor on
the chest wall.
The implant is next inserted together with a suction drain.
De-epithelialization and skin removal are completed, and the
breast skin is undermined in the superficial plane for about
2 cm, leaving the gland undisturbed. This will avoid detri-
180
Fig. 6 (a–d) Moderate-severe
a b
ptosis with important asymme-
try: periareolar scar mastopexy
with retropectoral anatomical
different size implants
c d
ment to the NAC blood supply. Indeed, the surgeon must
keep in mind that the implant position may reduce the blood
supply to the central portion of the breast.
When the circumareolar approach is used, a non-
resorbable purse-string suture is then performed to reposi-
tion the NAC. Wound closure is carried out with a two-layer
skin closure followed by compressive strips and elastic
bandage.
4.2 Circumareolar and Vertical Scar
Together with Dermoparenchymal
Rectangular Flap and Implant Insertion
Indications: Moderate to severe (third- and fourth-degree)
ptosis with significant skin excess (Fig. 7a–d).
Preoperative planning and marking are performed with
the patient in the upright position; marking is similar to that
described in the previous section.
Skin incision and de-epithelialization are first carried out
judiciously. The dissection proceeds to create the dual plane
pocket [7], first through the breast parenchyma to the upper
border of the areola, where the parenchyma is separated from
muscle, creating the retromammary part of the pocket. Next,
the lower border of the pectoralis major is defined and the
retropectoral plane is bluntly dissected, with the medial
aspect opened for 2–3 cm or more in relation to the degree of
muscle coverage of the upper portion of the implant and
glandular coverage of the lower portion.
The implant is then inserted together with a suction drain.
F. Stagno D’Alcontres et al.
The parenchymal pillars are then sutured together with
the flap with non-resorbable sutures to achieve better NAC
projection.
The lower pole skin excess is then treated: to avoid an
inverted T scar, the excess is removed in a vertical fashion
following the technique described by Lejour [15].
The NAC is repositioned through purse-string suturing,
and the incisions are closed with intradermal running
sutures.
The new breast shape is molded with elastic strips, which
also provide scar compression, and shape remodeling is
optimized by having patients wear a bra at all times for 1
month postoperatively.
The patient should be reminded that the immediate post-
operative aspect is different from the final one, and that the
breast will initially appear constricted in the lower pole while
the scars, particularly the vertical one, will look unnaturally
contracted during the first months. It typically takes 8–10
months before the final appearance of the breast shape and
scars is achieved.
Vertical scar mastopexy, together with the rectangular
dermoparenchymal flap, provides good and stable results,
with the vertical approach addressing the need for global
remodeling and reshaping of both the skin and glandular
components.
In cases of pseudoptosis or severe glandular ptosis, we
prefer to discard the midportion (triangular aspect) of the
glandular lower pole (Fig. 8), given the importance of reduc-
ing lower pole glandular excess to prevent recurrence of
glandular ptosis.
Mastopexy with Implants 181

Fig. 7 (a–d) Severe ptosis with a b

low asymmetry: circumvertical
periareolar scar mastopexy with
an inferior pedicle dermoglandu-
lar flap and anatomical retropec-
toral implants

c d

together with tenderness and swelling, sometimes in tandem

Fig. 8 Discarding the midportion (triangular) of the glandular lower
pole
5 Complications
Combined mastopexy augmentation is a difficult surgical
intervention, and complications may occur both early on
and later [16–20], depending on either the implant or the
surgical technique. The former include seroma and hema-
toma (1–2 %) [21], which present with increasing pain
with fever.
Small hematomas often spontaneously reabsorb with rest
and pain control for 15 days, whereas larger ones typically
require surgical evacuation, together with antibiotics and
anti-inflammatory drugs. Persistent large fluid collections
should be avoided, as their presence and potential drainage
may trigger capsular contracture [22].
Implant infection (1–4 %) [23] presents with pain and
tension, with the breast looking red and warmer; fever and
drainage from surgical wounds may also be present. In this
case, surgical intervention with implant removal, obtaining
microbiology specimens, and promptly initiating systemic
antibiotics, antiseptic rinsing of the submuscular pocket, and
implant exchange become mandatory.
One of the most challenging implant-related complica-
tions is capsular contracture, which is addressed elsewhere
in this book. Although no single cause has been definitively
implicated in capsular contracture, several conditions lead to
increased risk, with high incidence of capsular contracture
seen after hematoma and infection [24].
Smooth surface implants have also been related to a
higher incidence of contracture (31–86 %) than textured
implants [25]. Regarding implant position, submuscular
implants have a reportedly lower incidence of contracture
than subglandular ones [26], although the influence of sur-
face features in capsular contractures has been questioned in
more recent reports [27].
Another potential complication is implant dislocation,
which may occur when inadequate planning of the implant
182
size and/or over-undermining of the pocket is performed.
Over-undermining is often the result of the philosophy of
creating an adequate space for the implant as a strategy for
reducing capsular contracture [28].
If the lower pole constriction has not been released, or an
advanced capsular contracture has developed, an upward dis-
location is often produced. An inferior dislocation is the
effect of both erroneous choice in implant size and pocket
over-undermining. If the pocket is made too large, producing
a very thin capsule that does not counteract the effects of
gravity, the implant can drop down, leading to a bottoming-
out effect.
Lateral dissection should never proceed posterior to the
midaxillary line: when this boundary is violated, a lateral
dislocation occurs.
Medial over-undermining produces an internal bubble
deformity, and when exacted bilaterally can lead to approxi-
mation of the inner poles (symmastia).
Correction of implant dislocation is a difficult challenge,
which can include obliterating the excess pocket with cap-
sulorrhaphies, capsular excision/sutures, and/or double cap-
sular flaps.
Implant rotation can result from causes similar to those in
implant dislocation, and is a rare complication of anatomical
implant insertion. Treatment options typically include capsu-
lotomy, repositioning, and capsulorrhaphy [28].
Rippling typically occurs from placement of an under-
sized implant. Treatment is challenging, and consists of (a)
achieving better and soft tissue support (capsulorrhaphy or
capsular flaps even if approaches to ameliorate tissue quality
have been attempted with dermal substitutes) together with
(b) exchange for a larger implant [27].
Mondor’s syndrome is a rare (1 %) complication of
implant positioning, represented by a thrombophlebitis of
the superior superficial epigastric veins, clinically revealed
by a small cord between the IMF and the upper abdominal
skin. It resolves spontaneously in 4–6 weeks.
Some complications result directly from the surgical tech-
nique. Excess skin and/or fat and glandular resection, in
addition to inadequate preoperative assessment of pre-
existing anomalies of the breast, the chest wall, and/or the
column, may produce asymmetry. Surgical correction is
difficult, and breast remodeling, in conjunction with lipofill-
ing, is recommended [29].
Skin and/or NAC necrosis may occur as a product of
excess flap undermining and/or pedicle skeletonization,
especially in heavy smokers. Various degrees of NAC sensi-
bility reduction, from numbness to frank anesthesia, may
occur as an effect of mastopexy augmentation, and can be
produced either by postoperative edema after parenchymal
dissection, leading to a neuropraxia, or by a direct nerve
injury, producing definitive reduction in sensation.
F. Stagno D’Alcontres et al.
Skin necrosis can be treated with surgical debridement
together with local flaps or skin grafts (best taken from the
inner thigh for areolar resurfacing) when necessary.
Fat necrosis is a worrisome complication, as it can lead to
infection [29], and typically presents with yellowish secre-
tion from the surgical wounds. Given the risk of infection, it
should be treated with systemic antibiotics until resolution;
if it persists or recurs, it may require surgical drainage and
implant substitution. Significant scarring and contractures
can arise as an effect of this complication, which can be
effectively treated by lipofilling.
Some people develop rejection of sutures, particularly
resorbable sutures, with subsequent delayed healing, recur-
rent sinuses, granulomas, and infections, leading to hypertro-
phic scars [30]. Treatments with garments, compression,
steroid infiltration, and, eventually, scar excision have been
proposed, but are often inadequate.
6 Informed Consent
Both the surgeon and the patient should be conscious that
two procedures, implant insertion and skin-gland mastopexy,
are to be performed simultaneously, and that complications
from either procedure can occur. Particular care should be
taken preoperatively to document any degree of pre-existing
asymmetry. Each pitfall of these techniques should be ana-
lyzed and discussed throughout with the patient, ensuring
that augmentation mastopexy is an aesthetic operation, meet-
ing the high expectations of the high patient and the low tol-
erance degree for complications [8].
Pearls and Pitfalls
With mastopexy augmentation, one must keep in mind
that the added volume of the implant with the augmen-
tation can influence the technical requirements of the
planned skin resection with the mastopexy, and as
such it is best first to insert the implant and then
remodel the skin.
Provided that using the Tebbetts [7] pinch test, the
top of the oval periareolar pattern can be planned up to
6 cm from the IMF, carefully plan the proposed lift of
the NAC to avoid skin over-resection. This is achieved
by only resecting the medial and lateral skin to remove
the excess pigmented areola, de-epithelializing the
skin between the areola and the periareolar incision,
and then undermining up to 3 cm all round.
Plan an areolar diameter from 48 to 52 mm centered
on the existing areola and then make the periareolar
Mastopexy with Implants
purse-string diameter up to 40 mm to achieve a ten-
sionless final suture and a more natural appearance of
the lifted NAC.
In moderate cases, when the NAC is oriented down-
ward even after implant insertion, a superior pedicle
dermoglandular flap may be rotated upward to increase
NAC projection.
In wide, flattened breasts, and in cases with moder-
ate skin redundancy, adding a vertical scar (the circum-
vertical approach) is recommended. In situations
where the approach may provide a potential benefit,
placing the patient in the upright position intraopera-
tively is helpful to determine whether a circumareolar
approach alone is sufficient to provide a good breast
shape or if additional vertical skin resection is needed.
Only in cases of significant skin excess should an
inverted T pattern be proposed; parenchymal remodel-
ing through the vertical rectangular flap is then
mandatory.
References
1. Dufourmentel C, Mouly R (1959) La mastopexie. In: Dufourmentel
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2. Lalardrie J, Jouglard JP (1974) La mastopexie. In: La chirurgie
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3. Regnault P (1976) Breast ptosis. Definition and treatment. Clin
Plast Surg 3:193–203
4. Bostwick J (1983) Correction of breast ptosis. In: Aesthetic and
reconstructive breast surgery. CV Mosby, Saint Louis, pp 209–249
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6. Botti G (2007) Mastopexy in aesthetic surgery of the breast. SEE
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7. Tebbetts JB (2001) Dual plane breast augmentation: optimizing
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8. Hammond D (2006) Augmentation mastopexy: general consider-
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12. Spear SL (2000) Augmentation/mastopexy: “surgeon, beware”.
Plast Reconstr Surg 2003; 112: 905–906. Spear SL, Davison
SP. Breast augmentation with periareolar mastopexy. Open Techn
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13. Spear SL, Giese SY (2000) Simultaneous breast augmentation and
mastopexy. Aesthetic Surg J 20:155–165
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ited. Plast Reconstr Surg 107:1294–1299
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pexy: indications, operations, and outcomes. Ann Plast Surg
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17. Spear SL, Pelletiere CV, Menon N (2004) One-stage augmentation
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Freeman ME, Quardt SM, Hirsch EM, Cohen R (2006) Is one-stage
breast augmentation with mastopexy safe and effective? A review
of 186 primary cases. Aesthet Surg J 26(6): 674–681
18. Stevens WG, Stoker DA, Freeman ME, Quardt SM, Hirsch EM
(2007) Mastopexy revisited: a review of 150 consecutive cases for
complication and revision rates. Aesthet Surg J 27(2):150–154
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Hirsch EM (2007) One-stage mastopexy with breast augmentation:
a review of 321 patients. Plast Reconstr Surg 120(6):1674–1679
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pexy. Clin Plast Surg 36(1):105–115
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thickness of pseudosheath around silicone implants. Plast Reconstr
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Dis Clin North Am 3:275–287
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and the unilateral contracture. Plast Reconstr Surg 74:527
25. Caffee HH (1990) Textured silicone and capsular contracture. Ann
Plast Surg 24:197
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breast augmentation: a comparative study. Ann Plast Surg 8:370
27. Shestak KC (2006) Reoperative plastic surgery of the breast.
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28. Young VL, Watson ME, Atagi TA (2006) Secondary breast aug-
mentation. In: Mathes plastic surgery. Saunders, Philadelphia, p 323
29. Grotting JC (1995) Reoperative aesthetic & reconstructive plastic
surgery, vol 2. Quality Medical Publishing Inc, St. Louis
30. Bisbal Piazuelo J (2003) Cirugia Plastica Mamaria. Ponencia ofi-
cial del XXXVIII Congreso de la SECPRE, Barcelona
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edn. Lippincott Williams & Wilkins, Philadelphia
 Secondary Breast Augmentation
Pietro Berrino
1 Reoperation Rates After Breast
Augmentation
The “Inamed silicone breast implants core study” [1]
reported a 28.8 % reoperation rate within 6 years after pri-
mary breast augmentation and showed that one-quarter of
reoperated women required more than one reoperation
through 6 years.
The “Mentor core study on Memorygel breast implants”
reports a 15.4 reoperation rate at 3 years [2] and 19.4 at 6
years [3].
Breast augmentation is therefore the procedure associated
with the highest reoperation rate in aesthetic surgery.
As a consequence, breast augmentation is a frequent
cause of litigation, and although it is a routinely per-
formed operation with little technical difficulty in stan-
dard cases, it is to be considered a high-risk operation for
the surgeon.
Nevertheless, a 95 % satisfaction rate is reported [1] and
this theoretically badly matches the reported high incidence
of complications and reoperation rates. Patients’ satisfaction
and compliance are mainly related to psychological charac-
teristics: patients’ selection should include not only physical
features, but (primarily) psychological aspects. Patients with
unrealistic expectations, fragile, aggressive or irrational
women should be refused. Marital status, education, and, last
but not least, financial capabilities must be taken into account
before selecting a patient.
Preoperative information must include published
images showing complications and untowards results, and
these should be formally mentioned in the informed
consent.
P. Berrino, MD
Private Practice, Chirurgia Plastica Genova S.r.l., Genoa, Italy
e-mail: berrino@hotmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_15
2 Reasons for Reoperation After Breast
Augmentation
Capsular contracture (27.5 %), request for size/style change
(20.6 %), implant malposition (14.4 %) and ptosis (12 %) are
the reasons more frequently leading to reoperation [1].
However, other complications such as rippling, need for
biopsy, seroma, infection, extrusion and rupture have a sig-
nificant impact on the need for reoperation.
With the exception of requests for different implant style
or volume, which account for one reoperation out of five [1],
reasons for reoperation can be schematically grouped as
follows:
• Group 1: Complications due to implant modifications and
surrounding tissues’ reactions.
• Group 2: Complications due to body modifications.
The first group includes changes or modifications of the
implant structure and/or alterations in the surrounding tis-
sues provoked by the implant. Alloplastic material should
ideally be stable and inert. Decades of experience have
shown that, in spite of the continuous search for better
implants, even last-generation prostheses are far from being
stable and inert.
2.1 Implant Stability
Gel modifications, shell rippling and rupture are examples of
the lack of implant stability.
The inner gel can show colour changes even few months
after implantation (Fig. 1a), probably as a consequence of
shell permeability. The gel can have a yellowish serum-like
colour. This alteration is often encountered in conditions
leading to implant removal. Implants presenting brownish
material inside the shell have also been observed (Fig. 1b).
These observations confirm that there is an interaction
between surrounding fluids and the inner part of the implant,
185
186
a b
Fig. 1 (a) A last-generation anatomic implant showing deteriorated yellowish gel; (b) an implant showing deteriorated brownish gel; (c) mud-like
peri-prosthetic collection
with evident changes in the implant content. This interaction
represents a violation of the ideal stability. Hydrogel implants
represent another example of lack of stability, since they
showed long-term loss of the gel “structure” or osmotic pas-
sage of fluids from outside to inside the shell.
Creases in the shell are encountered in high-cohesivity
implants and are probably due to excessive pressure during
positioning. This alteration is often associated with visible
rippling or shape distortion even in women with a good sub-
cutaneous layer.
The 6-year by-implant rupture rate has been reported to
be 3.5 % and it increases to 15/17 % at 10 years [1–3].
Problems related to implant rupture, although less frequently
seen with last-generation implants, will therefore be encoun-
tered more often in the future.
2.2 Implant Inertness
Fluid collections, double capsules, capsular contractures and
erythematous reactions are examples of the lack of inertia of
breast implants.
Serum collections around the prosthesis are often seen at
sonography even years after implantation. This does not rep-
resent a clinical complication unless associated with volume
asymmetry or inflammation. Volume increase is often seen
during summer, because of the high external temperature and
sun exposure, and can be accompanied by discomfort, pain
and tenderness. Antibiotic and anti-inflammatory treatment
is advised. Patients are often very disturbed by this condition
which often arises when it is more difficult to hide the asym-
metry and represents a serious cause of anxiety and com-
plaint. Serum collection and subsequent volume increase can
subside on one side and start on the other one, adding good
P. Berrino
c
reasons for complaining. The aetiology of serum collection
is unclear and generally referred to an aspecific body reac-
tion. However, contamination with Staphylococcus epider-
midis or Mycobacteria has been demonstrated. It is uncertain
whether contamination occurs primarily or secondarily.
Infected serum can lead to implant exposure. This generally
happen in the lower breast quadrants, and most often in the
submammary scar. Submammary scars represent a weak
area subject to diastasis and implant exposure.
Other types of collection around the implant have been
described: brownish mud-like materials are probably the
result of a periprosthetic hematoma and/or silicone leakage
(Fig. 1c). The blood collection leading to this condition can
be due to an immediate blood loss or can happen several days
or months after the operation, since some patient described a
sudden volume increase occurring well after the operation.
Patients with this type of collection around the implant report
discomfort or pain, changes in the “feeling” of the implant
and contracture. The treatment is implant removal, debride-
ment and implant repositioning or mastopexy.
Capsular contractures using last-generation implants
are reported to have a by-patient rate of 14.8 % at 6 years
[1] and represent the most frequent reason for reoperation
(27.5 % of all reoperation). Calcified or nodular capsules
are commonly seen in case of silicone bleeding or implant
rupture (Fig. 2a). More rarely a double capsule is encoun-
tered, with an inner layer adherent to the implant, sur-
rounded by serum collection inside a smooth outer fibrous
capsule (Fig. 2b). The inner capsular layer can be soft or
constricted. When soft, the implant can easily be moved
inside the outer layer and the patient can dislocate the
prosthesis. This can have an important medico-legal aspect
since the patient can manually create a temporary defor-
mity by dislocating the implant (Fig. 3). When compressed
Secondary Breast Augmentation 187

Fig. 2 (a) A calcified capsule.

(b) A double capsule, hardly a b
compressing the implant. This
inner capsule was surrounded by
a normal non-contracted external
capsule, and was adherent to the
implant surface

Fig. 3 (a) A patient showing an

acceptable result 9 months after
a b
augmentation. (b) Due to the
presence of a soft double
capsule, this woman could
displace the implant towards
the axilla

by the inner capsule, the implant shows a stone-like hard-
ness and cannot be explanted through a short incision
unless the inner capsular layer is incised (Fig. 2b).
Erythematous spots around the implant are a less com-
mon problem which still needs investigation. This altera-
tion most often arises unilaterally at or below the outer
lower quadrant, few weeks to few months after implanta-
tion in a metameric fashion (Fig. 4). Hystologically vaso-
dilatation with perivascular inflammatory reaction is seen.
This phenomenon is resistant to local therapy and it can
subside spontaneously, but most often progresses until
implant removal. Nerve compression, reaction to metals,
subclinical infection and other aetiological factors are still
to be proven.
188
Fig. 4 An erythematous spot with a metameric contour: these reactions are
encountered along the intercostals space, laterally and below the implant
3 Body Modifications Around
the Implant: Weight Changes, Tissue
Thinning, Ptosis
The body undergoes physiological modifications which
influence the appearance of the augmented breast in the long
run and represent a frequent reason for reoperation. Weight
gain can make the augmented breast too big or ptotic.
Increase in the breast volume with or without weight gain
also represents a problem in several patients in their 50s. In
most women, explantation and breast reshaping represent the
best surgical choice. Weight loss represents a problem often
encountered in problematic patient (i.e. smoker or depressed
women), and is often associated with visible or palpable
implant contours or rippling. Tissue thinning appears to be
frequent around implants as a consequence of the presence
of the foreign body, even in the absence of weight loss. The
appearance of the augmented breast in such conditions dete-
riorates since it becomes more round, artificial and poor even
in the absence of major contour deformities. The improve-
ment of the defect caused by thinned tissue around the
implant represents a major challenge.
Ptosis physiologically occurs in the long term in women
who presented some breast volume before the operation or
P. Berrino
gain breast volume after the operation as a consequence of
weight gain or hormonal changes. Submuscular implants
tend to create an artificially full upper pole and to increase
the ptotic appearance of the breasts. Subglandular implants
tend to follow the ptotic breast and to create a low skin enve-
lope with empty upper quadrants.
A further problem due to dynamic changes in the sur-
rounding tissues is represented by dynamic deformities
occurring during pectoralis contractions above submuscular
prostheses. This represents a scientifically less debated prob-
lem which is, on the contrary, very often mentioned in
litigations.
4 The Correction of Complications
Due To Lack of Implant Inertness
and Stability
This group of complications includes capsular contracture
and implant rupture. The common features of these condi-
tions are implant dislocation and pocket distortion which
require treatment of periprosthetic tissues. Proper treatment
of the capsule by total, partial or localized capsulectomies or
capsulotomies is the key to aesthetically pleasing final out-
come, although improvements can be obtained by pharmaco-
logical treatment (leukotrien antagonists, specifically
Zafirlukast, given for 3 months) [4].
The objective severity of capsular contracture and the
subjective response to this complication suggest the need for
secondary surgery: Baker II contractures are usually well tol-
erated and do not usually require surgical correction, while
patients with Baker III contracture surgery usually request
implant replacement. Although the Baker classification rep-
resents a clinically helpful tool for the evaluation of capsular
contractures, a more objective assessment is provided by the
measurement of the “mammary compliance” [5]. Total
removal of the capsular tissue is not necessary unless it is
calcified or contains nodules of silicone. On the contrary, the
rigidity of the capsular tissue can be profitably used in order
to obtain a natural final shape. Capsular tissues must be
released where expansion and projection is needed, while
keeping the capsular layer in certain areas (e.g. the upper
pole) prevents undesired bulging [6].
Tissue release can be obtained by scoring capsulotomies,
keeping in mind that tissue gain is always perpendicular to
the direction of the incisions: vertical scoring produce hori-
zontal tissue release, while horizontal incisions produce ver-
tical gain. As a consequence, if the horizontal axis of the
breast is to be enlarged (vertically constricted mounds), ver-
tical incisions are mainly carried out (Fig. 5a), while hori-
zontal scoring is mainly performed if a more rounded inferior
pole is desired (Fig. 5b). If scoring appears to give insuffi-
cient release, periprosthetic tissues need being managed
more deeply: local capsulectomies must be performed
Secondary Breast Augmentation
a b
Fig. 5 (a) Horizontal capsulectomies and capsulotomies produce
vertical tissue release and gain. (b) Vertical capsulotomies and
capsulectomies produce horizontal tissue release and gain. (c) Total
a b
d e
Fig. 6 (Above a–c) A patient showing severe distortion 3 years after
submuscular breast augmentation: the left implant shifted downwards
and shows rippling at the upper outer quadrant. On the right side severe
contracture developed; (below d–f) the result after bilateral implant
perpendicularly to the desired tissue release. No scoring or
capsular removal is generally carried out in the upper portion
of the pocket, so that the upper pole will remain flat.
However, complete circular capsulotomy is always per-
formed, dividing the parietal capsule from the vault, in order
to allow the new implant to set more freely and surrounding
tissues to better adapt to the new tension lines (Fig. 5c).
Through this capsulotomy incision the pocket is enlarged
where needed, most often downwards below the existing
submammary fold. This type of management of capsular
189
c
circular capsulotomy is necessary to obtain adaptation of the sur-
rounding tissue to the new pocket
c
f
replacement: multiple capsulectomies and circular capsulotomy were
performed on the right side, while on the left side capsulectomies and
lower capsulorraphy were carried out
tissues provides solutions to different difficult conditions,
giving the surgeon the opportunity to:
• Modify the shape and size of the pocket
• Create areas where the rigidity of the capsule prevents
expansion and bulging
• Obtain tissue release exactly in the desired direction. It is
therefore a more creative and effective procedure for the
treatment of implant dislocations [6] than traditional total
capsulectomy (Fig. 6)
190
a b
Fig. 7 (a) A capsulorraphy is being performed in order to move the inframammary fold upwards: the two edges of the capsules will be sutured
along the new crease. (b) A capsular flap can be transposed to reinforce implant coverage in the areas of impending exposure
In capsular contracture leading to downward implant dis-
location, capsular tissue represents a strong structure to be
used to support the lower border of the new pocket and to
obtain definition of the new inframammary crease by capsu-
lorraphy (Fig. 7a).
Capsular tissue can be profitably used in case of
impending implant exposure. The area of impending
exposure can be reinforced by capsular flaps, which pro-
vide a reliable tissue layer (Fig. 7b). Infection, if not
severe, is not any more considered a contraindication to
implant replacement. Cultures should always be carried
out in order to provide proper antibiotic treatment. In case
of negative culture, Mycobacteria contamination should
be postulated and proper long-term antibiotic treatment
should be undertaken since Mycobacteria cultures require
several weeks and need to be carried out on tissue
samples.
5 The Correction of Complications
Due To Changes in Tissues
Surrounding the Implant
Tissue thinning represents a frequent reason for unsatis-
factory long-term results. Rippling and visible implant
contours can be improved by lipostructure, but patients
showing this problem are often very thin and do not have
suitable donor areas. Implant exchange is often advisable
and cohesive gel prostheses are usually suggested. Implant
with larger base diameter and moderate projection should
be used in these conditions in order to compensate for the
P. Berrino
lack of surrounding tissues. Weight gain should be con-
sidered and an appropriate dietary regimen should be
suggested.
Dynamic distortions are common deformities which are
often disregarded by women. When noticed, these deformi-
ties may become a serious reason for complaints. Dynamic
distortions can become more obvious several months after
the operation, when oedema subsides, tissue thinning
develops and pectoralis movements become stronger.
Surgical denervation of the pectoralis major muscle is the
most effective way of treatment [7].
Ptosis is often accompanied by increase in the volume
of breast parenchyma, which generally occurs in women
in the pre- or post-menopausal age. These middle-aged
patients are candidates for explantation and mastopexy, or
even simple implant removal. Implant removal represents
an acceptable option in patients without relevant aesthetic
requests: it often provides acceptable results in harmony
with the patient’s age without any additional scarring and
with little financial costs. Mastopexy is obviously the pro-
cedure of choice and, thanks to the increased breast vol-
ume, often provides satisfactory results without implant
replacement (Fig. 8). It is interesting to notice that most
of these women, although they have been satisfied for
many years with their breast augmentation, wish to have
the implant removed. In patients who had subglandular
augmentation, the capsular tissue can be used during mas-
topexy to strengthen the “new structure” of the breast
since this resistant tissue can be grabbed and moved by
internal sutures. Lipostructure or filler injection (hyal-
uronic acid) can be carried out in order to increase breast
volume in women undergoing implant removal.
Secondary Breast Augmentation 191

Fig. 8 (Above a, b) patient a b

showing the typical long-term
deformity after subglandular
breast augmentation; (Below
c, d) Implant removal and
mastopexy provide natural-
looking result and patient
satisfaction (Reproduced with
permission from: Berrino [6])

c d

References 4. Scuderi N, Mazzocchi M, Fioramonti P, Bistoni G (2006) The

effects of Zafirlukast on capsular contracture: preliminary report.
Aesthetic Plast Surg 30:1
1. Spear SL, Murphy KM, Slicton A et al (2007) Inamed silicone
5. Alfano C, Mazzocchi M, Scuderi N (2004) Mammary compliance:
breast implant core study results at 6 years. Plast Reconstr Surg
an objective measurement of capsular contracture. Aesthetic Plast
120(Suppl 1):8S
Surg 28:75
2. Cunningham B (2007) The mentor core study on silicone memory
6. Berrino P (2007) Surgical strategies in breast plastic surgery. SEE
gel breast implants. Plast Reconstr Surg 120(Suppl 1):19S
Editrice, Firenze
3. Cunningham B, McCue J (2009) Safety and efficacy of
7. Pelle Ceravolo M Presented at the XXth EURAPS Meeting,
Mentor MemoryGel implants at 6 years. Aesthetic Plast Surg
Barcelona, May 2009
33:440
 Inverted-T Scar Reduction
Mammoplasty
Michele Pascone and Andrea Armenio
1 Introduction
It is a widespread belief that a woman’s physical and mental
well-being can be influenced by the dimension, shape, and
symmetry of her breasts. In fact, an excessively large or exces-
sively small breast can determine in women an alteration in the
perception of their body image, a reduction in their self-esteem,
and in worst cases a degeneration of social relationships in both
public and private spheres. Moreover, women with breasts that
are excessively large compared to the rest of the body are often
limited in choice of clothes and in their lifestyle. Not to men-
tion the fact that an excessively large breast can make it diffi-
cult to perform some sports or even many of the daily life
activities, which are eventually substituted by sedentary activi-
ties, creating a vicious circle and contributing to patients’ isola-
tion. The dimension of a woman’s breast influences her life
style and her personal and professional choices.
Besides psychological problems, patients with large
breasts can have physical symptoms such as headache, cervi-
cal pain, backache and shoulder pain, inadequate posture
with shoulder incurvation, compression of the brachial
plexus with paresthesias of upper limbs, mastodynia, heavi-
ness and fullness, skin maceration at the inframammary fold,
intertrigo, and dermatosis (Table 1).
These symptoms can considerably improve or completely
disappear after reduction mammoplasty.
The fact that reduction mammoplasty is a procedure
which allows the plastic surgeon to improve the patient’s
M. Pascone, MD (*) • A. Armenio, MD
Dipartimento per le Applicazioni in Chirurgia delle Tecnologie
Innovative, Università di Bari, Bari, Italy
U.O.C. di Chirurgia Plastica e Ricostruttiva Universitaria,
Azienda Ospedaliero-Universitaria Policlinico di Bari
Bari, Italy
e-mail: michele.pascone@uniba.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_16
quality of life is also demonstrated by the fact that women
undergoing this operation are among the most satisfied. In
fact, after reduction mammoplasty patients often have a new
vision of life and are more prone to practice activities that
were previously precluded.
Breast hypertrophy surgery is in continuous evolution,
and always new expedients are proposed in order to improve
the results, make them more stable over time, and therefore
improve patients’ satisfaction.
2 History of Reduction Mammoplasty
The history of mammoplasty dates back to the sixth century BC
when Paulus Aegineta described the first surgical operation for
the treatment of gynecomastia. Recent history of breast surgery
dates back to the beginning of the fourteenth century when Hans
Schaller performed the first breast amputation. In 1848,
Dieffenbach was probably the first to perform a reduction mam-
moplasty by removing the inferior two thirds and the posterior
segment of the breast, leaving a scar in the inframammary fold
[1]. Thomas [2] and Guinaud [3] emphasized the use of the
inframammary fold as an access route for the removal of exces-
sive tissue from the inferior portion of the breast.
The technical modifications proposed at the end of 1800
and beginning of 1900 mainly aimed at correcting the descent
of the nipple-areola complex (NAC). Several types of skin
and glandular excisions were proposed, and they all consisted
Table 1 Summary scheme of the most frequent discomforts caused by
breast hypertrophy
Problems related to large breasts
Local: mastodynia, heaviness and fullness, skin maceration at the
inframammary fold, intertrigo, and dermatosis
Aesthetic and psychological
Oncological: the volume hides small tumors
Functional: shoulder incurvation, inadequate posture, neck and
shoulder pain, compression of the brachial plexus
193
194
of positioning the breast at an upper position on the thoracic
wall but without a real NAC transposition [4].
Between 1909 and 1925, the concept of NAC transposi-
tion was introduced and improved. In 1909, Morestin was
probably the first to perform the transposition of the NAC,
followed by Villandre in 1911, Lexer [4] in 1912, and Thorek
[5] in 1921.
In 1928, Biesemberger described a technique of reduction
mammoplasty that consisted of the dissection of the skin
from the entire mammary gland and the excision of a wedge
of tissue. The final scars had an anchor shape. Complications
were basically due to skin necrosis.
For this reason, in the operations described by other
authors in the following years, they tried to preserve the vas-
cularization of the skin, mammary gland, and NAC during
reduction mammoplasty. In particular more attention was
paid on the skin overlying the residual mammary gland.
Following the publication by Aubert [6] in 1923, most
surgeons tried to prevent skin necrosis by leaving the skin
adherent to the mammary gland through the subdermal
plexus. In case it was necessary to remove a large amount of
tissue, the reduction was either performed in a single step or,
in particular cases, in two surgical steps.
In 1930, Schwarzmann recommended to leave a ring of
dermal tissue around the areola in order to improve the arte-
rial and venous circulation of the NAC. This expedient
seemed to improve the survival of the NAC and to ease its
transfer, and it paved the way to the techniques that consist of
the de-epithelialization of the nipple-carrying pedicle.
Subsequent modifications of the reduction mammoplasty
techniques involved the skin incisions and the design of the
pedicle in order to improve the vascularization of the tissues
and to place the scars in less visible areas.
In 1956, Wise [7] described a pattern for the preoperative
drawing of the breast that gave reproducible results and min-
imal complications, associated with satisfying breast shapes.
The Wise pattern is still widely used.
Ariè in 1957 and Pitanguy in 1964 described two tech-
niques that had in common the upward transposition of
the NAC by using a superior dermal pedicle and that left
anchor-shaped scars. In 1960, Strombeck [8] described a
horizontal bipedicle flap for the transposition of the NAC
that helped to maintain the innervation through the lateral
connections.
The technique described by Skoog in 1963 instead is
based on a lateral pedicle with an extremely reduced thick-
ness compared to those described by the other surgeons. The
advantage was the ease of movement of the pedicle without
excessive breast distortions, but there was a high risk of areo-
lar necrosis. McKissock [9, 10] described a vertical bipedicle
flap, Weiner [11] described a superior-based flap, Orlando
[12] and Guthrie a superomedial-based flap, and Courtiss
and Goldwyn [13] and Georgiade [14] used an inferior-based
pedicle. With these technical expedients it became easier to
M. Pascone and A. Armenio
maintain an adequate blood flow and innervation of the NAC
in reduction mammoplasties.
Although the first description of the superior dermal pedicle
was attributed to Weiner et al. [11] in 1973, Pitanguy [15] had
already described several years before (1964) the technique of
the dermo-parenchymal pedicle and of the superior dermal ped-
icle. The limits of the technique by Pitanguy were the quantity
of mammary tissue that could be removed (maximum 600 g)
and the reduced transposition of the NAC (maximum 7.5 cm).
During the following years, some authors tried to solve this last
inconvenient by increasing the thickness of the superior pedicle.
However, in this case an excessive distortion of the nipple-are-
ola complex with tendency to retraction was determined.
Since then, several authors have better described the
innervation of the breast, making possible techniques with
shorter scars. Even if some of these techniques have been
described at the end of the 1970s and the beginning of the
1980s, they became popular only several years later.
Some authors have also used liposuction, alone or in asso-
ciation with other reduction techniques, with fair results.
3 Classification of Breast Hypertrophies
The concept of “normal breast” is very difficult to define. It
varies according to several patients’ characteristics such as
race, age, and constitution (Fig. 1).
Being conventionally established as “normal” a 250–
300 cc breast volume, breast hypertrophy is defined when the
breast is bigger than 50 % of this volume.
Subsequently, it is possible to define a “moderate” hyper-
trophy when it requires the removal of 150–300 cc of tissue.
“Marked” hypertrophies are those in which 300–800 cc of
Fig. 1 Ideal breast measures (The concept of breast aesthetical beauty
is indefinable, and this confirms the saying: “beauty is in the eyes of the
beholder”)
Inverted-T Scar Reduction Mammoplasty
Table 2 Approximate evaluation of the quantity of tissue to be
removed according to body parameters
Body type, height, weight, breast volume
Longitype 152–172 cm 45–54 kg 150–250 cc
Normotype 152–172 cm 54–63 kg 250–350 cc
Brachytype 152–172 cm 63–72 kg 350–600 cc
tissue is removed. “Severe” hypertrophies are those in which
the removed tissue varies from 800 to more than 1,000 cc
(Table 2).
Breast volume depends on several tissue components. In
fact, breast dimension is not directly related to the quantity
of the mammary gland. The main component in the breast is
the adipose tissue. The glandular and connective components
are present in variable quantities.
As a consequence, it is possible to classify breast hyper-
trophies also according to the main component:
• Glandular hypertrophy
• Adipose hypertrophy
• Connective hypertrophy
4 Philosophy of Reduction
Mammoplasty
The choice of the surgical technique to reduce breast volume
depends on several factors. There is no technique that gives
better results compared to the others, and it would be unreal-
istic to think that it is possible to use a single technique for
the correction of all types of breast hypertrophies. On the
contrary, the best surgical technique should be chosen
according to the specific case.
Factors affecting the choice of the surgical technique are
numerous: the size and characteristics of the breast (main
adipose, glandular or connective component), the NAC posi-
tion, the volume of the tissue to be removed, the age and the
desires of the patient, and the preference of the surgeon.
According to our opinion, an important aspect to discuss
with the patient before selecting the surgical technique is the
length of the scar and the breast shape in the immediate post-
operative period.
There are surgical techniques that convey shorter scars in
spite of a less pleasant breast shape in the immediate postop-
erative period and, therefore, require a longer period of
adjustment so that the breast takes an acceptable shape.
Other surgical techniques are able to guarantee a pleasant
and stable result but involve longer scars.
After deciding, together with the patient, the type of result
that is wished and that is possible to obtain, the surgeon will
choose the preoperative drawing and the nipple-carrying
pedicle to use.
195
5 Classification of the Surgical
Techniques
The techniques of reduction mammoplasty can be classified
according to the type of nipple-carrying pedicle, the skin
drawing and the subsequent residual scar, and the type of
glandular resection to perform.
6 Choice of Pedicle
As we already mentioned, the choice of the nipple-carrying
pedicle depends on several factors. The pedicles that can be
used are:
• Superior
• Superomedial
• Superolateral
• Inferior
• Medial
• Lateral
• Vertical
• Horizontal
7 Skin Drawing and Scar Shape
The choice of the nipple-carrying pedicle does not necessar-
ily influence the skin drawing and the residual scars. For
example, if we use a superior pedicle, we can choose a draw-
ing with vertical residual scar (areola-mammary groove) or
L or J scars or also inverted-T scar.
The choice of the drawing is therefore determined
according to the skin and glandular resection to be per-
formed. In case of extensive skin laxity or very big breasts,
it is necessary to make a drawing that results in an
“inverted-T” scar. In case of little reductions in young
patients with good skin quality, it is possible to opt for a
vertical scar.
Schematically, it is possible to classify the types of resid-
ual scars in the following way:
• “Inverted-T” or “anchor” scar (Strombeck [8] 1960,
Pitanguy [15] 1960, McKissock [9, 10] 1972) (Fig. 2)
• Lateral and oblique scar (Dufourmentel-Mouly 1961)
(Fig. 3)
• Small “T” or “L” scar (Regnault [16] 1974, Bozola [17]
1982, Peixoto [18] 1980) (Fig. 4a, b)
• Vertical scar (Ariè [19] 1957, Lassus [20], Lejour [21,
22]) (Fig. 5)
• Periareolar scar (Hinderer [23] 1975, Benelli [24] 1989)
(Fig. 6)
196 M. Pascone and A. Armenio

Fig. 2 Schematic drawing of the “inverted-T” or “anchor” scar Fig. 3 Schematic drawing of the oblique lateral scar

a b

Fig. 4 (a, b) Schematic drawing of the small “T” or “L” scar

Fig. 5 Schematic drawing of the vertical scar Fig. 6 Schematic drawing of the periareolar scar
Inverted-T Scar Reduction Mammoplasty
8 Anatomy
Breast anatomy is very complex, and we will limit this brief
description to the principal concepts that allow us to better
understand the anatomical basis of superior and inferior ped-
icle mammoplasty.
8.1 Vascularization
The breast tissue is highly vascularized by the internal mam-
mary artery medially, the thoracoacromial and thoracodorsal
arteries superiorly, branches of the lateral thoracic artery, and
several intercostal perforating vessels that pierce the pectora-
lis major muscle or that originate inferiorly to it.
There is a superficial and deep periareolar plexus.
However, it is advisable to preserve the most part of vascu-
larization during reduction mammoplasties because there is
a great variability between individuals on the dominant
vascularization.
8.2 Innervation
Breasts are widely innervated by the anterior rami of the lat-
eral cutaneous branches of the 3rd to 6th intercostal nerves
laterally and by the anterior branches of the 2nd to 6th inter-
costal nerves medially. The skin of the upper pole of the
breast is innervated by the supraclavicular branches of the
cervical plexus. The nipple-areola complex (NAC) is mainly
innervated by the deep portion of the breast, usually from the
third, fourth, and fifth anterior cutaneous nerves and the
fourth and fifth lateral cutaneous nerves.
Some authors [25] studied the innervation of the breast
and confirmed that the innervation of the nipple-areola com-
plex involves the lateral cutaneous branches from the third to
the fifth intercostal nerves and the anteromedial branches of
the intercostal nerves from the second to fifth. Several nerves
have been recognized as responsible for the innervation of
the nipple. Most of them run on the surface of the gland and
converge beneath the NAC to form the plexus. The contribu-
tion of each nerve varies between the different corpses stud-
ied, and in the same individual it varies between the left and
right sides. The lateral cutaneous branch of the fourth inter-
costal nerve contributed to the innervation of the NAC in 11
out of 12 corpses. This nerve has two branches: a superficial
branch that innervates the NAC and a deep branch, on the
surface of the pectoralis major muscle, that curves inferolat-
erally which then becomes superficial and innervates
the NAC.
This study led by Sarhadi et al. [25] suggested that the
innervation and the sensitivity of the nipple are maintained
by both superior and medial pedicles, even if the dissection
197
of the tissue on the pectoralis muscular fascia is discouraged
in order to preserve as many nervous branches as possible. It
is important to evaluate the sensitivity of the NAC before
surgery because many patients complain of a postoperative
reduced sensitivity. It should also be mentioned that, on the
contrary, some patients notice an increased sensitivity of the
nipple which cannot be explained on an anatomical basis, but
that could be due to psychological reasons in view of the
improved appearance of the breast, increased self-esteem,
and improved body image.
9 Superior Pedicle Reduction
Mammoplasty with Inverted-T Scar
In this first part, only the techniques involving superior-
based flaps will be discussed.
9.1 Inverted-T Scar in Superior
Pedicle Flaps
The skin drawing that results in an inverted-T scar can be
used with superior, superomedial, and superolateral nipple-
carrying pedicles.
The inverted-T scar can be used in both small, medium-
sized, and hypertrophic breasts. This type of skin incision
allows to mold the breast in a reproducible manner, to
remove the excessive skin component to a variable extent,
and to immediately obtain optimal results that are stable
over time.
Schematically, it is possible to define the principles that
determine the choice of superior pedicle reduction mammo-
plasty with inverted-T scar:
• Moderate hypertrophies that require a limited glandular
resection (300–800 g)
• 1st- and 2nd-degree ptosis
• Limited NAC transposition (8–10 cm maximum)
• Patients that do not need to breastfeed
• Breasts with a noncompletely volume-depleted upper
pole
The advantages of the superior pedicle reduction mam-
moplasty with inverted-T scar are:
• Fast and relatively simple procedure
• Pleasant breast shape from the immediate postoperative
period
• Major replenishing of the upper pole
• Reduced risk of NAC necrosis
• Good preservation of the sensitivity and contractility of
the nipple
198 M. Pascone and A. Armenio

• Absence of “bottoming out” and “square breast” (more

frequent in the case of inferior pedicle)
• Stable result

The disadvantages of the superior pedicle reduction mam-

moplasty with inverted-T scar are:

• Transverse scar that is occasionally visible medially and

laterally
• Maximum advised nipple transposition of 8–10 cm (some
authors perform transposition of more than 20 cm [26]);
• Not indicated in case of excessively connective (compact)
breasts because of the difficulty in folding the superior
pedicle without compromising the vitality of the NAC
• Reduced possibility of breastfeeding after surgery [27]
Fig. 7 Patient positioned with the arms along the body

9.2 Indications to the Surgical Procedure

The indications to superior pedicle reduction mammoplasty

mid line of sternum

ian
are in common with the other reduction mammoplasties and

erid
are related to the symptoms and clinical objectivity that the

increase in breast volume and weight determine. Among
these signs and symptoms, there are backache, pain in the
cervical region and shoulders, lumbosacral pain, musculo-
tensive cefalea, chronic mastitis, wrong posture with kypho-
sis and/or lordosis and arthritis of the spinal cord, excessive
tension of the bra straps over the shoulders with formation of
furrows, paresthesias due to the compression of the brachial
plexus, intertrigo of the inframammary fold, and difficulty in
everyday life activities or sports as well as social discomfort
and problems in wearing “normal” clothes. The authors sug-
gest using this technique for breast reductions of less than
800 g per breast with skin excess. In case of bigger reduc-
tions, it is advisable to choose an inferior or vertical pedicle.
9.3 Contraindications
The contraindications to superior pedicle reduction mammo-
plasty are mainly related to the presence of scars that can
interfere with the vascularization of the pedicle, i.e., that
pass across the pedicle interrupting the blood flow to the
NAC. Another contraindication is a previous reduction mam-
moplasty with a non-superior pedicle. Relative contraindica-
tions are the removal of more than 800 g of breast tissue or a
nipple transposition of less than 5 cm or more than 10–12 cm.
Some authors reported transpositions of more than 18 cm,
but in this case the risk of NAC necrosis increases dramati-
cally. Another relative contraindication is represented by
smokers, for which the risk of skin necrosis or liponecrosis is
increased.
st m
brea
inframammary
crease
Fig. 8 The main lines are drawn. (1) Middle sternal line, (2) breast
meridian, (3) inframammary fold.
In superior pedicle reduction mammoplasty with inverted-
T scar, the preoperative drawing is of utmost importance and
represents the scheme to follow in order to remove the tissue
from the areas where it is excessive and save the mammary
gland and the skin where necessary in order to convey a
pleasing appearance, a volume that is proportionate to the
rest of the body and to obtain a stable result.
9.4 Preoperative Drawing: Wise Pattern
(or “Keyhole”)
The patient is standing or sitting with the arms along the body
and the shoulders at the same level (Fig. 7). Firstly, the supra-
sternal notch and the midsternal line are marked (Fig. 8).
Successively, the midclavicular point is marked (6–7 cm from
the suprasternal notch) and the line of the breast meridian is
Inverted-T Scar Reduction Mammoplasty 199

drawn, not necessarily passing through the nipple (Fig. 8). In
case the nipple is more medial or lateral compared to the
breast meridian, this line serves to reposition the nipple in the
central portion of the breast with a more symmetrical position
and equally distant from the midsternal line on both breasts.
The inframammary fold is marked with the arms down
and with the arms up to make sure of the actual position of
the fold (Fig. 8). In some cases of breast asymmetry, in fact,
the fold could be higher in one of the breasts.
The neo-nipple will be placed at the level of the projection of
the inframammary fold on the anterior surface of the breast, as
shown in Fig. 9. The nipple can be at a different height accord-
ing to the patient’s characteristics (height, characteristics of the
thorax, and characteristics of the breast). However, the position
of the neo-nipple cannot be less than 17–18 cm from the clavicle
along the midclavicular line. The ideal position should be
around 19–22 cm along the midclavicular line or 20–23 cm
from the suprasternal notch along the midclavicular line.
The preoperative drawing of the NAC is made by hand or
by using a template as shown in Fig. 10a, b.
We draw a circumference open at the inferior pole with a
superior margin placed 1.5–2 cm higher than the position of the
neo-nipple along the previously drawn breast meridian. The
circle with a slightly flattened shape should have a 14–16 cm
circumference. The circumference will be open at the lower
pole as shown in Fig. 12. The breast is rotated medially, and a
6–7 cm line is drawn from the inferior portion of the circumfer-
ence along the line passing through the central point of the infra-
mammary fold as for reaching the breast meridian. The same
maneuver is repeated rotating the breast laterally (Fig. 11a, b).
The two lines B–D and C–E (Fig. 11c) that will form the
pillars of the breast will represent the portion of scar that

Fig. 9 The neo-nipple is drawn at the level of the projection of the inframammary fold on the anterior surface of the breast on the breast
meridian

a b

Fig. 10 (a) Template with metallic thread expressly modeled; (b) template realized with a semirigid plastic paper
200
a b
Fig. 11 (a) The breast is gently rotated inward and (b) outward in order
to draw the lines of the lateral pillars. Such lines should be the ideal
continuation of the breast meridian. (c) Detail of the measures of the
Fig. 12 Keyhole completed
goes from the inferior margin of the areola to the central
point of the inframammary fold and should have a 5–7 cm
length. The angle between these two lines can be increased
or reduced according to the size of the areola and to the
quantity of tissue to be removed. From the caudal portion of
the two lines (B–D and C–E), we draw the other segments
(straight or S shaped) that will reach the lateral and medial
portion of the breast and will then join a line drawn along the
inframammary fold or 1–2 cm higher than that (Fig. 12). The
following step consists of drawing the pedicle and the por-
tion of the areola and nipple to be transposed. Most patients
that undergo a reduction mammoplasty have an enlarged and
sometimes asymmetrical areola. During the operation, the
areola is not entirely transposed but only a part of it with the
nipple in the center. In order to improve the final aesthetic
outcome, it is therefore preferred to draw around the nipple a
M. Pascone and A. Armenio
c
keyhole. Line A is the superior portion of the new nipple/areola com-
plex, Lines B-D and C-E represent the portion of scar from the inferior
margin of the areola to the central point of the inframammary fold
circle with a 4–4.5 cm diameter that will be the neo-NAC to
be transposed. The neo-areola is drawn by hand or by using
a template while the assistant keeps the skin of the breast
moderately stretched. The diameter of the neo-areola, as pre-
viously mentioned, should not measure more than 4–4.5 cm.
At this point, we can draw the nipple-carrying pedicle that
can be superior, superomedial, or superolateral according to
the surgeon’s preference.
The pedicle should have a superior base of at least 5–6 cm
and should include a portion of tissue of at least 2 cm around
the neo-NAC in order to guarantee an adequate blood supply
and a sufficient venous drainage (Figs. 13 and 14).
The area delimited by these lines, marked in blue in
Fig. 14, will be the portion of the skin and mammary gland
to be removed in order to reduce the breast volume, while the
area marked in red (Figs. 13 and 14) will be the nipple-
carrying pedicle to be preserved.
We will describe the superior pedicle technique although
the same procedures can be performed for the other two ped-
icles (superomedial and superolateral) as well.
9.5 Surgical Technique
The operation is performed with the patient in supine posi-
tion with the arms opened at 70° or slightly abducted with
the hands crossed and placed on the suprapubic region. With
this last position, the tension on breast tissues is reduced and
a more precise idea of the final result can be obtained. Some
authors prefer to inject the local anesthetic with epinephrine
before starting the operation in order to reduce the intraop-
erative bleeding. However, this procedure can hide a bleed-
ing that can occur at the end of the operation with the risk of
postoperative hematoma formation [28–30].
Inverted-T Scar Reduction Mammoplasty
Fig. 13 Schematic images of
the preoperative drawing in
superior pedicle reduction
mammoplasty “with inverted-T”
scar
Fig. 14 Drawing of the superior nipple-carrying pedicle
The first step of the operation consists of the de-
epithelialization of the nipple-carrying pedicle that is per-
formed with a surgical blade (#10 or 20) or with Mayo scissors.
This procedure saves the skin of the areola and the nipple of
the previously drawn neo-NAC, as shown in Figs. 15 and 16,
leaving a 1–2 cm ring of tissue around the areola in order to
assure an adequate blood supply. The width of the base of the
pedicle should be at least 5–6 cm in order to assure an ade-
quate blood flow and an appropriate venous drainage. In order
to ease the de-epithelialization, it is possible to use instru-
ments such as the Mammostat (Fig. 15) or simply a gauge
long enough to tighten the base of the breast to determine an
201
Fig. 15 De-epithelialization performed with scissors
adequate tension of the breast skin. In fact, under tension the
de-epithelialization of the pedicle is extremely easy.
At the end of the de-epithelialization, we proceed to the
removal of the glandular and cutaneous tissue from the lower
pole and the lateral and medial portion en bloc. It is useful to
remark that the tissue removal should be slightly bigger on
the lateral side and slightly smaller on the medial one in order
to maintain an adequate breast volume medially and as a con-
sequence a pleasing shape of the breast (Figs. 17 and 18).
The following step consists of the incision of the pedicle
along the borders of the de-epithelialized area with a surgical
blade or an electrosurgical pencil, according to the prefer-
202
Fig. 16 De-epithelialized pedicle
Fig. 17 Removal of the inferior
portion of the breast
M. Pascone and A. Armenio
ences of the surgeon. In this step, it is very important not to
damage the surrounding skin in order to avoid the sufferance
of the tissues and an impaired healing with unpleasant cica-
tricial outcomes.
After incising the pedicle along the borders following a
vertical line, we proceed to the sculpting of the flap in its
inferior portion (Fig. 19a). The pedicle should have a distal
thickness of at least 2 cm in order not to compromise the
vascularization of the nipple-areola complex (NAC) and to
allow an adequate filling of the upper pole of the breast. The
flap is then made thicker going up to the fascia of the pecto-
ralis muscle. The thickness of the flap can be reduced when
the tissue is particularly dense and does not allow the folding
of the pedicle on itself to fix the areola to the point A
(Fig. 11c) of the preoperative drawing (of the keyhole)
Inverted-T Scar Reduction Mammoplasty
(Fig. 18b). At this point, in case it is necessary to reposition
the breast tissue at a higher position, it is possible to dissect
along the fascia of the pectoralis major muscle up to the sec-
ond or third rib.
The removal of tissue can now be improved and adapted
to the preoperative requests of the patient. After removing
the excessive tissue according to the preoperative drawing,
the suture of the upper part of the NAC to the superior mar-
gin of the keyhole (point A) is performed with a 3/0 resorb-
able stitch (Figs. 19 and 20a, b).
If a superomedial or superolateral pedicle is used, we will
perform the same maneuver with the rotation of the nipple-
carrying pedicle upward.
The next suture in a 2/0 resorbable stitch, is placed to
join the base of the pillars with the central point of the infra-
mammary fold (Fig. 21a, b). In this way, we have a sugges-
Fig. 18 Detail of the superior nipple-carrying pedicle after the removal
of the inferior portion of the breast
a b
Fig. 19 (a) Sculpting of the flap
along the previously drawn
margins, (b) suture of the upper
pole of the areola to the superior
margin of the keyhole folding
the nipple-carrying pedicle on
itself
203
tive view of the shape and projection of the breast. Another
suture is placed to join the cranial portion of the pillars with
the lower pole of the areola. In alternative to the stitches, it
is possible to use the Bakhous or Bernard pincers or metal
clips.
In case the glandular and cutaneous resection is adequate,
we can suture the two pillars by single interrupted sutures,
starting from the deep planes and trying to obtain a good
facing in order not to leave empty spaces in the lower pole,
to prevent the diastasis of the pillars, and to give an adequate
support to the breast as well as an adequate projection
(Fig. 22a).
The placement of drainage tubes is not always necessary.
Some authors maintain that the tubes reduce the risk of hema-
toma; however, this has not been demonstrated [31, 32].
The drainage tube can come out from:
• The axilla
• The lateral part of the surgical wound without performing
other incisions
• The lateral part of the breast along the line of the bra in
order to disguise the scar with the underwear
The suture of the breast can be performed with single
stitches on the subcutis and completed with an intradermal
suture in resorbable thread (Figs. 22b, 23, and 24).
In our opinion, the dressing is of utmost importance as it
helps modeling the breast and preventing hematomas and
seromas during the first stages of healing [16].
9.6 Dressing
The dressing consists of the placement of Steri-Strip on the
sutures and dry sterile gauzes, and the compression is per-
formed using paper tape on the inframammary fold and then
laterally and medially in order to create a triangle.
204 M. Pascone and A. Armenio

Fig. 20 Schematic drawings of

a b
the superior flap sculpted (a)
and the first stitch to anchor the
areola to the highest point of the
keyhole, folding the pedicle on
itselft and in turn lifting it
upwards (arrow) (b)

a b

Fig. 21 Schematic drawings of

the anchoring stitches to mold
the breast. Securing the closure
downward (arrows) (a). The
inverted-T design of the final
scar is evident (b)
Inverted-T Scar Reduction Mammoplasty
Fig. 22 (a) Subcutaneous
a b
stitches. (b) Final intradermal
suture
Fig. 23 Result at the end of the operation
Pearls and Pitfalls
The authors maintain that some simple expedients,
mentioned below, can prevent or at least reduce the
complications, contribute to obtain optimal results,
and prevent possible medicolegal sequelae:
• The authors suggest that patients undergo a mam-
mography or at least a breast ultrasound before
surgery in order to identify possible cancer tissue
that could change the kind of operation to
perform.
205
• Make sure that smokers gave up smoking at least
one month before surgery in order to reduce postop-
erative complications.
• The preoperative drawing should be extremely
accurate with the patient standing. The lines must
be traced with permanent markers that are not
erased during the preparation of the surgical field
by alcoholic disinfectants. In case a line is traced in
a wrong position, it is advisable to erase it accu-
rately in order not to mix up the lines during
surgery.
• In case the preoperative drawing is performed the
day before surgery, it is advisable to place some
gauzes on the inframammary fold and the breast in
order to avoid sweating and rubbing of clothes
which can erase the drawing.
• In the operating room, immediately before starting
the operation, it is advisable to mark with methy-
lene blue the key points. The procedure consists of
dipping a 22-gauge needle into a container with
methylene blue and driving it into the skin in cor-
respondence of:
– Point A of the keyhole
– Point of conjunction of future pillars
– Central point of the inframammary fold
In this way we will create a temporary tattoo that
enables us to easily identify the reference points
for the anchoring of tissues. Less expert sur-
geons may find it difficult to recognize the key
points and could accidentally create breast
distortions.
206
Fig. 24 Scheme of the breast
before and after surgery
• Always request the histological analysis of the
removed tissue because, although it is rare, it is pos-
sible to find a neoplastic tissue.
• During surgery handle the tissues in an atraumatic
manner: this allows to prevent cutaneous and adi-
pose necrosis. The good quality of the outcome can
be compromised by a rough manipulation of the tis-
sues that determines alterations of the vasculariza-
tion along the skin margins of the removed areas.
This will reflect on the quality of the scars that
could become diastatic and dyschromic. The glan-
dular and adipose tissues can also be affected by an
erroneous manipulation with the possible onset of
liponecrosis in the postoperative period.
• It is advisable to perform the removal of glandulo-
adipose and cutaneous tissue in excess in a gradual
manner. It is always possible to remove an addi-
tional quantity of tissue in a later phase of surgery.
Moreover, the removal of tissue must be performed
according to precise anatomical planes. In some
cases, it can occur that the plane is erroneously mis-
taken because of the tension produced by hypertro-
phic tissues with the risk of removing an excessive
quantity of tissue. In these cases, it is useful to ask
the assistant to keep the hypertrophic breast in a
M. Pascone and A. Armenio
medial position eliminating the tendency of the
breast to go laterally distorting the tissues.
• The modeling of the breast after the removal of
excessive tissue should be performed with well-
positioned resorbable sutures by facing the tissues
in a precise manner. This allows to obtain an accept-
able shape since the very beginning and a stable
result and to avoid possible visible or palpable
irregularities on the breast surface. Also the skin
suture should be very accurate in order to avoid a
diastasis of the scars.
• An extremely important element to take into
account during the reduction mammoplasty is,
according to our opinion, the minimum blood loss
and accurate hemostasis. The anesthetist should be
able to reduce the blood pressure during the initial
phases of surgery in order to reduce useless bleed-
ings and to bring the blood pressure back to normal
values during the final phases in order to identify,
before the definite closure, possible vessels to coag-
ulate or ligate [33].
• The dimension of the areola before surgery should
not be over 4–4.5 cm in diameter with the skin
slightly tense. If bigger diameters are used, a few
months after surgery, the areola will be stretched by
Inverted-T Scar Reduction Mammoplasty
the traction operated by the surrounding tissues,
and it appears distorted, excessively big, and with
dyschromic scars.
• The shape of the areola can, in some cases, be slightly
distorted at the end of the operation (i.e., inverted
drop shape) because of the traction operated by the
tissues. In these cases, the authors suggest to remove
additional periareolar tissue in order to immediately
obtain a satisfying shape. The most frequent risk, in
case these defects are not corrected, is that the distor-
tion of the areola becomes permanent.
• The authors suggest to place the patients in semi-
sitting position before the definite closure of the
breast in order to evaluate the effects of gravity on
the breast and to identify possible inaccuracies in
the conization of the breast.
• The postoperative elasto-compressive dressing and
the drainages in our experience help reducing hema-
toma formation [34] that can occur because of the
sudden increase in blood pressure values during the
patient’s awakening. Therefore, we suggest to wake
the patient only after completing the dressing.
10 Inferior Pedicle Reduction
Mammoplasty with Inverted-T Scar
A hypertrophic breast can be present in young and in older
patients (Figs. 25 and 26). In teenagers, the hypertrophic
a b
Fig. 25 26 year old female. Wise pattern (a) preoperative photograph; (b) 2-year postoperative photograph
207
tissue is distributed in a homogeneous manner in the entire
breast. In elderly patients, the breast is usually ptotic, flat-
tened, and with an enlarged areola. In these patients, the
base of the breast can even contain only skin and subcuta-
neous tissue with the breast parenchyma being concen-
trated in the lower pole.
The inferior pedicle reduction mammoplasty with
inverted-T scar appears ideal in order to correct this type of
alterations in both medium-sized breasts than in gigantomas-
tia of young and elderly patients; in fact, the transverse com-
ponent of the “T” mammoplasty allows to resect all the tissue
that is necessary, while the vertical component allows to
realize the conization of the breast.
The operation consists of the harvesting of traditional
dermo-adipose flaps and of a dermo-glandular flap with an
inferior axial vascularization based on the perforating vessels
from the internal mammary artery that contains also the inter-
costal nerves to the NAC as described by E. Wuringer [35].
This flap is transposed upward in order to guarantee the aug-
mentation of the upper and medial pole of the new breast.
Schematically, we can define the principles that determine
the choice of an inferior pedicle reduction mammoplasty:
• Marked hypertrophies requiring a considerable glandular
resection (from 800 g up to more than 2 kg)
• High degree of breast ptosis (grade III or IV)
• Breast tissue mainly localized at the lower pole
• Need of a considerable transposition of the NAC (up to
15–20 cm)
• Patients that did not have any pregnancy or that do not
need to breastfeed after surgery
• Breasts with a completely depleted upper pole
208
The advantages of the inferior pedicle reduction mammo-
plasty are:
• Pleasant aspect of the breast shortly after surgery
• Rather stable result over time
• Reduced risks of NAC necrosis
• Good preservation of the nipple sensitivity and
contractility
• Resolution of the marked ptosis
• Fast and rather easy procedure
• Predictable results
• Replenishment of the upper pole
• Ideal also for breasts with a mainly connective structure
(compact)
• Possibility to maintain the lactation after surgery
The disadvantages of the inferior pedicle reduction mam-
moplasty are
• Maximum transposition of the nipple of 15–20 cm (even
if some authors perform transpositions up to 25–30 cm).
• Transverse scar occasionally visible medially and
laterally.
• Tendency of the breast to descent downward (“bottoming
out”).
• In some cases the breast takes a square shape (“boxy
breast”).
10.1 Surgical Indications
The indications for the inferior pedicle reduction mammo-
plasty are common to the other reduction mammoplasties
and have been previously described in the section relative
to the superior pedicle reduction mammoplasty with
inverted-T scar. The authors suggest to use this breast sur-
gery technique for reductions that do not exceed 500 g per
breast.
10.2 Contraindications
The contraindications of inferior pedicle reduction mammo-
plasty are mainly related to the presence of scars from previ-
ous surgeries that can interfere with the vascularization of
the pedicle by interrupting or reducing the blood flow to the
NAC. Relative contraindications are the transposition of the
nipple of more than 20–25 cm. Some authors described
transpositions over 30 cm; however, in this case the risk of
M. Pascone and A. Armenio
NAC necrosis increases dramatically. In case of gigantomas-
tia with the need of considerable transposition of the NAC, it
is advisable to perform a reduction mammoplasty with free
grafting of the nipple [36]. In fact, in these patients the
sensitivity of the NAC can be already compromised before
surgery so that the harvest of a nipple-carrying pedicle is not
justified. Moreover, in smokers, the risk of skin necrosis or
liponecrosis is increased.
10.3 Preoperative Drawing: Wise Pattern
(or “Keyhole”)
As for the preoperative drawing, please refer to the
description given for the superior pedicle technique
(Figs. 13 and 14). The only difference is the drawing of
the pedicle (Figs. 27 and 28).
The inferior pedicle is drawn starting from the inframam-
mary fold, and it should have a base of at least 10 cm in order
to allow an adequate blood supply to the NAC. In case the
inferior flap is particularly long, it is advisable to increase in
a proportional way the base of the pedicle (up to 14–16 cm).
The drawing of the pedicle will have as axis the breast merid-
ian, and it should comprise a portion of tissue of at least 2 cm
around the NAC in order to guarantee an adequate
vascularization.
10.4 Surgical Technique
The initial step of the surgical procedure consists of the de-
epithelialization of the nipple-carrying pedicle. Such proce-
dure can be eased by the use of a Mammostat or a gauze tight
at the base of the breast. This expedient allows to distend at
most the skin of the breast so that it can be easily de-
epithelialized with a surgical blade or Mayo scissors. The
de-epithelialization concerns all the previously drawn pedi-
cle, except the neo-NAC.
Upon completion of the de-epithelialization, the
Mammostat or the gauze is removed and the incision is
performed along the drawing previously made (keyhole
and nipple-carrying pedicle), in order to avoid that the
drawing can be accidentally erased when cleansing the
operative field with the gauzes. The sculpting of the pedi-
cle is performed along the borders with a surgical blade or
an electrosurgical pencil, according to the surgeon’s
preference.
At this point, the nipple-carrying flap is sculpted along
the two sides perpendicularly to the skin surface. In this
phase, it is very easy to perform an excessive resection of
Inverted-T Scar Reduction Mammoplasty 209

a b

Fig. 26 Wise pattern (a) preoperative photograph (b) 2-year postoperative photograph

a b

Fig. 27 Wise pattern (a) preoperative photograph (b) preoperative drawing (c) 6-month postoperative photograph
210
Fig. 28 Drawing of the inferior pedicle
the pedicle with the risk of damaging the vessels of the
pedicle. The authors suggest to let an assistant help you
keeping the breast in a central position in order to reduce
at least this risk. After sculpting the pedicle laterally,
we can proceed by partially lifting the pedicle paying
attention to keep an adequate thickness in the distal and
proximal portion in order to guarantee an adequate vascu-
larization of the NAC.
The nipple-carrying pedicle can have a variable thick-
ness. In the distal portion, it should be at least 2 cm, and
we can increase the thickness proceeding caudally in order
to preserve as many perforating vessels as possible. The
authors suggest to preserve the blood vessels running in
the suspensory ligament of the breast, described by
Wuringer et al. [35], especially in case of very large
breasts, in order to reduce at least the risk of vascular suf-
ferance of the NAC.
After harvesting the pedicle, the cutaneous, adipose,
and glandular tissue in excess can be removed according
to the “keyhole” drawing. In some cases, it is necessary to
remove additional tissue according to the characteristics
of the breast paying attention not to excessively deplete
the medial pole, which would result in an unpleasant
neckline. In case of need, it is preferable to remove tissue
from the lateral portion of the breast rather than from the
medial region.
M. Pascone and A. Armenio
At this point, we can proceed with the creation of a
retromammary pocket by lifting the superior dermo-adi-
pose flaps from the pectoralis major fascia up to the sec-
ond to third rib above, the inframammary fold below, and
laterally in a variable way according to the characteristics
of the breast. This procedure has the function to allow a
redistribution of the breast tissue during the suturing
phase (glanuloplasty) to create the neo-breast. The
removal of tissue can then be further improved and
adapted to the surgeon’s need and/or to the patient’s pre-
operative requests (Fig. 29).
The accurate hemostasis in this phase represents a cru-
cial point. The authors suggest to increase the blood pres-
sure to the normal values for the patient, in accordance
with the anesthetist, in order to verify if there are patent
vessels that could cause postoperative hematomas. It is
useful to remember that arterial and venous vessels of
hypertrophic tissues are also hypertrophic themselves, and
therefore, they can easily cause postoperative hemor-
rhages, even of large quantity.
Once the removal of excessive tissue and an accurate
hemostasis are performed, we proceed with the suture, in
resorbable material, of the upper pole of the NAC to the
superior margin of the keyhole (point A). Some anchoring
sutures of the pedicle to the pectoralis fascia can be
positioned at the base of the flap in order to prevent the
Inverted-T Scar Reduction Mammoplasty
Fig. 29 Detail of the lateral view of the breast with the inferior pedicle
lifted after the removal of the excessive tissue
“bottoming out.” The following suture, in resorbable 2/0
thread, is positioned to connect the base of the pillars to
the central point of the inframammary fold (Fig. 21a, b).
In this way, we will have an approximate view of the
shape and projection of the breast. Another suture is posi-
tioned to connect the cranial portion of the pillars to the
inferior pole of the areola. As an alternative to the sutures,
it is possible to use the Bakhous or Bernard pincers or
metal clips.
In case the cutaneous and glandular resection is adequate,
we can start suturing the two pillars with resorbable single
sutures, starting from the deep planes and trying to obtain a
good facing of the tissues in order not to leave empty spaces
in the lower pole, to prevent the diastasis of the pillars, and
to give an adequate support as well as an adequate projec-
tion to the breast.
The positioning of the drainage tubes does not differ from
the description given for the superior pedicle reduction
mammoplasty.
The suture of the breast can then be continued in single
sutures and completed with an intradermal suture in resorb-
able material (Fig. 30).
211
Fig. 30 Completion of the sutures
According to our opinion, the dressing is of utmost impor-
tance as it helps modeling the breast and preventing hemato-
mas during the first healing phases.
10.5 Dressing
The dressing consists of the placement of Steri-Strip along
the sutures and dry sterile gauzes, and the compression is
performed with stripes of paper tape placed at the inframa-
mmary fold and then laterally and medially to form a
triangle.
Pearls and Pitfalls
As for the considerations about practical advices and
mistakes to avoid, please refer to the section relative
to the superior pedicle reduction mammoplasty.
In fact, we believe that the previously described
considerations are also valid for the inferior pedicle
mammoplasty.
212 M. Pascone and A. Armenio

11 Clinical Cases

Figures 31, 32, 33, 34, and 35.

a b

c d

Fig. 31 (a, b) Preoperative aspect; (c, d) 2-year postoperative aspect

Inverted-T Scar Reduction Mammoplasty 213

a b

Fig. 32 (a) Preoperative aspect; (b) 6-month postoperative aspect; (c) 2-year postoperative aspect

a b

Fig. 33 (a) Preoperative aspect; (b) 1-year postoperative aspect

214 M. Pascone and A. Armenio

a b

Fig. 34 (a) Preoperative aspect; (b) 1-year postoperative aspect

a b

Fig. 35 (a) Preoperative aspect; (b) 1-year postoperative aspect

Inverted-T Scar Reduction Mammoplasty
12 Reduction Mammoplasty
with Inverted-T Scar in Breast
Hypertrophies of Mild and Severe
Entity Associated with Marked Ptosis:
Notes of Personal Technique
M. Pascone
12.1 Introduction
Belonging to this group are the breast hypertrophies that
require an average glandular exeresis with a minimum of
700–800 g up to over 1,000 g to participate in more accept-
able breast models, socially and psychologically speaking.
It is appropriate to underline that some currently available
techniques, studied to reduce as much as possible the cicatri-
cial outcomes, if used over a certain degree of hypertrophy,
risk to lose sight of a balanced harmony between the quantity
of scars and the shape and volume of the breast. In these
cases, in fact, the authors maintain that it is better to use tech-
niques that allow to better model the breast rather than tech-
niques that privilege a shorter scar at all costs. In cases of
breast hypertrophy complicated by a marked ptosis, the
upper pole is depleted because the gland slides downward
and gathers in the lower pole of the breast assuming an aspect
that the woman, especially if young, accepts with difficulty.
The woman with such a clinical situation is indeed deeply
motivated by the desire of regaining a more pleasant volume
and shape of the breast, and this desire is even stronger than
the possibility of having a longer scar.
The main objectives of a reduction mammoplasty are to
reach the following:
• A pleasant shape shortly after surgery
• A real replenishment of the upper pole of the breast
• A correction of the ptosis of the lower pole more stable
over time
As for the first objective, the authors believe that in the
choice of the surgical technique, it is important to follow the
“tailor” principle according to which, in order to obtain an
optimal cutaneous modeling, longer incisions, and as a con-
sequence longer scars, are needed.
As for the other two objectives, the authors think that the
vertical pedicle technique or vertical bipedicle McKissock
type [9, 10], especially used in hypertrophies of mild and
severe entity and with marked ptosis, offers several advan-
tages compared to other techniques:
• Easy programming
• Rather simple execution
215
• Good projection
• Valid dermal support to the lower pole
• Long-lasting result
Starting from these premises and referring to the most
recent anatomical data on the vascularization and innerva-
tion of the areola and nipple described in the literature, the
authors have substantially modified the McKissock tech-
nique in order to optimize its advantages.
The data recently reported by Wuringer [35] confirm the
existence of a septum in the mammary gland called the sus-
pensory ligament of the breast that originates at the level of
the fifth rib and runs horizontally toward the areola.
In its thickness run (a) the most important nerve of the nip-
ple, that is, the deep ramus of the cutaneous lateral branch of the
fourth intercostal nerve, and (b) the vessels that provide vascu-
larization to the areola and nipple and that run in two planes:
• In a cranial plane, the thoracoacromial artery and a branch
of the lateral thoracic (or external mammary) artery
• In a caudal plane, the perforating vessels of the 4th and
5th intercostal artery
These anatomical data presume that if the vessels and
nerves in the ligament are preserved, the vascular supply of
the superior dermo-glandular pedicle is not indispensable for
the vitality of the areola and nipple and that, if necessary, a
further glandular resection both above and below the suspen-
sory ligament of the breast can be performed without any
risk for the vitality of the residual breast (Fig. 36a, b).
In the light of these anatomical data, the modifications
that the authors made to the McKissock technique and that
have been used in the last 15 years involve:
• The inferior or subareolar pedicle: it is larger than
McKissock’s (as if it was an inferior pedicle technique)
and it allows a better suspension of the gland.
• The supra-areolar pedicle: being unnecessary for the vas-
cularization, it is cut, and becoming completely mobile, it
is sutured at a higher position below the upper pole of the
mammary gland, thus lifting the lower pole (Fig. 36b).
12.2 Surgical Technique
The preoperative drawing (keyhole) is the same as described
previously (Fig. 37). The nipple-carrying pedicle is vertical
with a width of about 12 cm at the inframammary fold and
about 6–8 cm at the supra-areolar portion.
With the help of the Mammostat, the pedicle is com-
pletely de-epithelialized (green area in Figs. 37 and 38).
Then, we proceed with the sculpting of the pedicle and the
216 M. Pascone and A. Armenio

Fig. 36 (a) Scheme of the a b

removal of the mammary tissue
from the upper and lower pole
leaving intact the suspensory
ligament of the breast and the
inferior flap with the vessels that
supply the NAC; (b) anchoring
of the portion of the supra-
areolar pedicle at the level of
the second rib

Fig. 37 Preoperative drawing

according to Wise. In green, the
vertical pedicle. In red, part of
the glandulo-cutaneous tissue to
be removed

Fig. 38 De-epithelialization of the vertical nipple-carrying pedicle

Inverted-T Scar Reduction Mammoplasty 217

Fig. 39 Detail of the de-epithelialized pedicle. Removal of the mammary tissue in excess from the medial and lateral region and from the ret-
roareolar region

a b

Fig. 40 (a) Detail of the flap with the superior, central, and inferior pedicle; (b) detail of the detachment of the superior flap allowing anchoring
at the level of the second rib

removal of the glandulo-cutaneous areas medial and lateral
to the pedicle (Fig. 39). A further resection of the glandular
and adipose tissue is performed at the upper pole and in the
area comprised between the inferior pedicle and the mam-
mary ligament (Fig. 40). In this phase special attention
should be paid not to injure the vessels that run in the suspen-
sory ligament of the breast.
Once the removal of the excessive mammary tissue is com-
pleted, it is possible to cut the superior pedicle, i.e., the portion
of the supra-areolar tissue (Fig. 40a, b), and anchor it on the
fascia of the pectoralis major muscle at the level of the second
rib with a 2/0 resorbable suture (Fig. 41b). In this way the
whole breast goes back up with a stable anchoring that avoids
the “bottoming out” typical of the inferior pedicle techniques.
The following phases of suture of the breast are the same
as described previously for the superior pedicle reduction
mammoplasty (Fig. 42).
The advantages derived from the mobilization of the
superior flap and its anchoring at a higher position on
the thoracic wall (fascia of the pectoralis major muscle)
are:
• An easier upward transposition of the nipple-areola com-
plex that is free from connections
• A real and concrete replenishment of the upper pole that
is usually depleted
• A longer correction of the ptosis as a result of the higher
anchoring of the residual mammary gland
218 M. Pascone and A. Armenio

a b

Fig. 41 (a) The superior pedicle is cut and (b) anchored on the fascia of the pectoralis major muscle at the level of the second rib

12.3 Complications

The complications related to problems of vascularization are

almost inexistent in the personal technique described if the
anatomical principles on which this technique is based are
respected. However, generally speaking, complications are
those reported in the chapter of the techniques of superior
and inferior pedicle reduction mammoplasty.

Fig. 42 After anchoring the superior portion of the pedicle to the fascia
of the pectoralis major muscle, the areola is anchored at the point A of
the keyhole
Inverted-T Scar Reduction Mammoplasty 219

13 Clinical Cases

Figures 43, 44, 45, 46, 47, 48, 49, and 50.

Fig. 43 Surgical programming with the patient standing and lying. It is possible to note the distance between the inframammary fold and the
areola (14 cm) and the width of the pedicle in the inferior portion (12 cm)

Fig. 44 De-epithelialization of
the vertical pedicle
220 M. Pascone and A. Armenio

Fig. 45 Removal of the portion of retroareolar tissue leaving intact the

de-epithelialized vertical pedicle

a b

Fig. 46 (a) Preoperative image; (b) 2-year postoperative result

Inverted-T Scar Reduction Mammoplasty 221

a b c

Fig. 47 (a, b) Preoperative aspect in lateral view; (c) 3-month postoperative result

a b c

Fig. 48 (a, b) Surgical programming; (c) 1-year postoperative result

222 M. Pascone and A. Armenio

a b c

Fig. 49 (a, b) Surgical programming; (c) 1-year postoperative result

Fig. 50 (a) Preoperative image;

a b
(b) preoperative drawing; (c–d)
2-year postoperative images

c d
Inverted-T Scar Reduction Mammoplasty
14 Complications of Reduction
Mammoplasties
The complications of reduction mammoplasty are rare; how-
ever, as in any other surgical procedure, they can occur caus-
ing lengthening of the postoperative treatment and,
exceptionally, the need of a surgical reintervention.
14.1 Bleeding and Hematoma
The onset of a hematoma is one of the most frequent compli-
cations, and in many cases it is caused by a diffuse bleeding
rather than a single vessel bleeding. If the size of the hema-
toma is bigger than 20 cc (evaluated by ultrasound), it is neces-
sary to reoperate on the patient to remove the hematoma and
perform an accurate hemostasis. The small-sized hematomas
usually reabsorb. Infrequently, it can be necessary to perform
a percutaneous drainage with a peripheral venous catheter.
14.2 Seroma
It is a collection of serum in the operated tissues. It usually
appears later after surgery and may require percutaneous
drainage of the collection by a venous catheter.
14.3 Infection
The infection can complicate every surgical procedure. It can
occur in the immediate postoperative period or at a later time
after surgery. It manifests with fever, pain, erythema, and tension
in the treated area. It usually resolves with antibiotic therapy, but
sometimes it can be necessary to drain a purulent collection.
14.4 Necrosis
It can occur on the skin, nipple-areola complex, or glandulo-
adipose tissue (liponecrosis). The presence of necrotic tissue
can inhibit the healing of the surgical wounds and require a
correction. It can be due to an infection, a vascular sufferance
of the tissue, or a wound dehiscence. Cigarette smoking can
interfere with the healing processes increasing its incidence.
14.5 Pathological Scars
Usually the quality of the scars is good, but sometimes,
because of a specific individual reactivity, such scars increase
in consistency and thickness (hypertrophic scars or cheloids)
and/or widen (atrophic).
223
14.6 Dysesthesia of the Nipple-Areola
Complex
Any breast surgery can cause temporary increase or decrease
in nipple and/or breast sensitivity. Only occasionally it can
present a permanent character. It is useful to perform an eval-
uation of the sensitivity before surgery and compare it with
the postoperative one.
14.7 Dyschromia of the Nipple-Areola
Complex
The quality of the periareolar scars is usually very good.
Occasionally, a hypopigmentation of the areola or nipple can
occur as a consequence of necrosis or cutaneous vascular
sufferance. In some cases it is possible to solve the hypopig-
mentation with a tattoo.
14.8 Unsatisfactory Outcome
The breasts, just like other parts of the body, present a certain
degree of asymmetry. As such, an asymmetry of the breasts
in shape and volume is also possible after surgery. We sug-
gest to discuss these aspects with the patient before the oper-
ation. It is useful to discuss with the patient also the possibility
of performing further surgeries in order to correct all the
defects that should eventually remain after surgery (dog-
ears, atrophic scars, asymmetries, etc.).
15 Informed Consent
The aim of the present consent paper is to offer the patient,
in addition to the preoperative conversation with the sur-
geon, the information regarding the characteristics and the
risks related to reduction mammoplasty. Please read care-
fully the following, discuss with the surgeon the explana-
tion of every term that is not clear, and then sign this
document as a confirmation of having understood the
information given.
The reduction mammoplasty is the operation that
reduces and remodels a big-size breast (breast hypertro-
phy or gigantomastia). The operation causes the presence
of cutaneous scars, at least one around the areola and
another vertical one that goes from the areola to the infra-
mammary fold; in many cases it is also necessary to make
a scar along the inframammary fold. During the operation
drainage tubes will be placed coming out from the armpit.
These will be left in place for a few days after surgery and
will be removed either before discharge or at the outpatient
visit. After surgery it is normal that the sensitivity of the
224
nipple-areola complex decreases, but in most cases it
comes back to normal after a few months. The function of
breastfeeding can be altered (depending on the surgical
technique). The aesthetic outcome could be compromised
by a subsequent pregnancy or considerable weight varia-
tion. In order to maintain the result, when standing it is a
good practice to always wear a bra.
It is normal that in the first postoperative period, the
breasts appear excessively high, swollen, and unnatural and
that along the vertical scar and around the areola, some
creases can be present that will disappear in a few months. In
order to obtain a satisfying aesthetic result, it is usually nec-
essary to wait 3–4 months. In order that the scars whiten, it is
necessary to wait one year.
15.1 Before the Reduction Mammoplasty
• Inform the surgeon of any pharmacologic treatment
(especially cortisone, contraceptives, antihypertensive
drugs, cardioactive drugs, anticoagulants, hypoglyce-
mic drugs, antibiotics, tranquilizers, sleeping drugs,
stimulants, etc.).
• Suspend the consumption of drugs containing acetylsali-
cylic acid (i.e., Alka-Seltzer®, Ascriptin®, aspirin,
Bufferin®, Anacin®, Ecotrin®, Excedrin®, etc.).
• Stop or reduce smoking at least 1 week before surgery.
• Immediately inform the doctor of the onset of cold, sore
throat, cough, or skin diseases.
• Buy a soft-cup bra.
• Arrange the presence of an accompanying person in the
postoperative period, as it can be very useful, although
not indispensable.
15.2 The Day Before Surgery
• Have an accurate shower, remove the makeup from the
face and the nail polish from the fingers and the toes,
shave the armpits, and remove the jewels.
• Do not drink or eat anything from midnight on.
15.3 The Day of Surgery
• Keep fasting and wear nightclothes that can be completely
opened in the front and with large sleeves.
M. Pascone and A. Armenio
15.4 After Surgery
• At the time of discharge, have somebody drive you home.
• It is advisable to allow yourself 4–5 days of rest at home.
• Do not smoke for at least a couple of days in order to
avoid coughing and as a consequence possible bleedings.
• A cautious return to sexual activity not before 15 days is
allowed.
• Do not drive for at least 1 week.
• Do not perform wide movements with the arms and do
not lift weights for at least 2 weeks.
• Sports activities can be restarted after 1 month.
• Avoid direct exposure to the sun or intense heat (i.e.,
sauna, UVA sunlamp) and do not sleep on your belly for
at least 2–3 months.
• It is possible to take a shower only after the removal of the
stitches.
15.5 Possible Complications Related
to Reduction Mammoplasty
Complications, although rare, can occur as in any sur-
gical procedure causing lengthening of the postopera-
tive treatment and, exceptionally, the need of a surgical
reintervention.
Such complications can be:
• Bleeding and hematoma: Every surgical procedure
involves the risk of bleeding or hematoma (collection of
clotted blood within the tissue). The small-sized hemato-
mas usually reabsorb like any bruise; in case of bigger
collections, it is necessary to drain them in order to allow
a proper healing.
• Seroma: It is a collection of liquid within the operated tis-
sues. It rarely causes long-term problems; however, occa-
sionally, it should be drained.
• Infection: The infection can complicate every surgical
procedure. It can occur in the immediate postoperative
period or at a later time after surgery. It manifests with
fever, pain, erythema, and tension in the treated area. It
usually resolves with antibiotic therapy, but sometimes it
can be necessary to drain a collection.
• Dysesthesia of the nipple-areola complex: Any breast sur-
gery can cause temporary increase or decrease in nipple
and/or breast sensitivity. Only occasionally it can present
a permanent character.
• Pain: It can be related to the surgical procedure or it can
be associated with other possible complications (infec-
tion, seroma, hematoma). It can be managed with analge-
sics or by removing the initial cause.
Inverted-T Scar Reduction Mammoplasty
• Necrosis: It can occur on the skin, nipple-areola complex,
or glandulo-adipose tissue (steatonecrosis). The presence
of necrotic tissue can inhibit the healing of the surgical
wounds and require a correction. It can be due to an infec-
tion, a vascular sufferance of the tissue, or a wound dehis-
cence. Cigarette smoking can interfere with the healing
processes increasing its incidence.
• Pathological scars: Usually the quality of the scars is
good, but sometimes, because of a specific individual
reactivity, such scars increase in consistency and thick-
ness (hypertrophic scars or cheloids) and/or widen
(atrophic).
• Unsatisfactory outcome: Asymmetry of the breasts,
shape, and volume that differ from the expectations. We
suggest to discuss these aspects with the surgeon before
the operation.
Poor quality scars as well as small residual asymmetries
(frequent in big reductions) may require a further revisal
operation at a later time.
References
1. Dieffenbach JF (1848) Die operative Chirurgie, vol 2. Brockhaus,
Leipzig, p 370
2. Thomas TG (1882) On the removal of benign tumours of the
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3. Guinard M (1903) Comment on: Rapport de l’ablation esthetique
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8. Strombeck JO (1960) Mammoplasty: report of a new technique
based on the two pedicle procedure. Br J Plast Surg 13:79–80
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10. McKissock PK (1976) Reduction mammoplasty by the vertical
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3:309–320
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Surg 85:728–738
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8:231–236
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Am Cir Plast 3:28
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Plast Reconstr Surg 97:373–380
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breast. Plast Reconstr Surg 94:100–114
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mammary scar and with breast liposuction. Perspect Plast Surg
4:67
23. Hinderer UT (1990) Chapter 44. Development of concepts in
reduction mammoplasty and ptosis. In: Georgiade NG, Georgiade
GS, Riefkohl R (eds) Aesthetic surgery of the breast. WB Saunders
Co, Philadelphia
24. Benelli L (1990) A new periareolar mammoplasty: the “round
block” technique. Aesthetic Plast Surg 14:93–100
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areola. Br J Plast Surg 49:156–164
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Superior pedicle breast reduction for hypertrophy with massive pto-
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Scuderi N (2008) Breastfeeding after reduction mammoplasty
using different techniques. Aesthetic Plast Surg 32(2):294–297
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caine with adrenaline in reducing pain and bleeding associated with
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(2009) When to use drains in breast reduction surgery? Ann Plast
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(2009) Draining after breast reduction: a randomised controlled
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 Vertical Breast Reduction
Diego Ribuffo, Matteo Atzeni, and Francesco Serratore
1 Introduction
Before the 1900s, attempts to reduce breast size were limited
to volume reduction without regard to nipple position and
viability, not to breast shape. In the first part of the twentieth
century, multiple techniques were described to move the
nipple-areola complex and to reduce bulk. To maintain via-
bility, two-stage procedures were often recommended, even
if this is nowadays hard to believe.
As time progressed, surgeons focused on better preserva-
tion of nipple sensation, skin flap circulation, and shape.
Various pedicles and resection techniques were described,
each with advantages and disadvantages [1, 2].
It soon became clear that (1) a dermoglandular or central
pedicle was better for maintaining an optimal blood supply
to the nipple-areola complex (and this has found recent con-
firmation with the work of Wuringer et al. [3], leading to the
septum-based mammaplasty) and (2) extensive skin under-
mining (as in Biesenberger’s technique) was to be avoided
because of possible vascular compromise.
While in North America and in Australia (where bigger
reductions were common) the inferior pedicle technique
combined with an inverted-T closure proved to be most effec-
tive and eventually became the workhorse of the inverted-T
approach as an evolution of the vertical bipedicle McKissock
reduction [4], in Europe the superior pedicle technique with
its variation (superolateral, superomedial) had more success.
D. Ribuffo, MD (*)
Dipartimento di Scienze Chirurgiche e
Odontostomatologiche, Università di Cagliari, Cagliari, Italy
e-mail: diegoribuffo@libero.it
M. Atzeni, MD
Unità di Chirurgia Plastica, Dipartimento di Chirurgia,
Università di Cagliari, Cagliari, Italy
e-mail: teo.atzeni@tiscali.it
F. Serratore, MD
Dipartimento di Chirurgia ‘P.Valdoni’, U.O.C. di Chirurgia Plastica
e Ricostruttiva, Università di Roma “Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_17
In an effort to reduce scars during the 1990s, both in Europe
and in South America, surgeons obtained good results with
various types of short T scars/circumareolar techniques asso-
ciated with the superior pedicle, although with time these pro-
cedures were restricted to small reductions or mastopexies.
Dissatisfaction with these procedures, on the part of the
patient and the surgeon alike as a result of unsightly scars
and long-term “bottoming out” of the breast, has promoted
the search for alternative methods of breast reduction.
At the end of the twentieth century, finally, an old and aban-
doned technique was reintroduced into practice and gained
more and more success: the vertical mammaplasty. Although
the impact of this method was in the beginning focused on
avoiding the unsightly horizontal scar, surgeons realized soon
that the biggest advantage would be with shape and long-last-
ing results with the bonus of increased projection.
Nowadays, the vertical reduction has many technical vari-
ations and is achieving more and more worldwide apprecia-
tion, although many senior surgeons (especially in the USA)
still continue to use the traditional inferior pedicle with
inverted-T closure.
2 Evolution Leading to Vertical
Breast Reduction
“Short-scar” or vertical reduction mammaplasty has been
described in various versions by several authors [5], includ-
ing Lassus and Lejour [6–8], both of whom “rediscovered”
the vertical reduction mammaplasty and have extensive
experience with this procedure. Differently from Lassus,
Lejour’s technique [8] included liposuction and a wide skin
undermining. However, the short-scar reduction techniques
described by these authors did not immediately achieve
widespread acceptance in the USA, largely because many
surgeons were unable to obtain optimal results in a consis-
tent fashion unless using it for small reductions/pexies.
During the same time, other surgeons took inspiration
from Lassus’ work [6] and slightly modified his technique
227
228
which in our minds deserves credit for the growing popular-
ity of the vertical reduction with both patients and surgeons.
In 1999, Hall-Findlay [9] described a vertical reduction
mammaplasty based on a superomedial pedicle. Because of
its relative simplicity, this technique was adopted by many
surgeons seeking improvement on the limitations of the Wise
pattern mammaplasty [10]. Hidalgo [11] then eliminated
liposuction as a major integral component of the procedure,
as well as suture of the gland to the pectoralis muscle. In
adjunct, he did not undermine the lower pole skin and
avoided an overly wide skin resection and tight wound clo-
sure that in his experience produced significant lower pole
distortion in the early postoperative period.
However, a number of complications were still identifi-
able with these procedures. These include kinking of the
pedicle in the very fibrous breast, an ill-defined inframam-
mary fold, and poor nipple-areola sensitivity. Indeed, breast
sensation following use of the superior pedicle technique
was significantly compromised up to 6 months after surgery,
as previously reported by several authors.
The recent discovery of the importance of the horizontal
septum in reduction mammaplasty has been emphasized by
Hamdi et al. [12]. In their technique, a medial/lateral vertical
reduction is carried out preserving Wuringer’s septum and
with it the fundamental blood and nerve supply to the nipple-
areola complex.
In summary, the key to the increased success of this tech-
nique over time simply lies in the pattern of parenchymal
resection, which is only vertical. This explains most of its
advantages, like the ideal projection obtained, and the long-
lasting results. If resection is also horizontal, there’s no doubt
this will flatten the breast. Also, if the parenchymal scar is
only vertical, this will act as an internal brassiere.
3 Author’s Approach
3.1 First Steps
The technique we use is very similar to Hamdi et al. [12]’s
vertical reduction, though combining the advantages of
Hidalgo’s [11] approach. The patient is marked in the stand-
ing position preoperatively (Fig. 1a–c). The midline, infra-
mammary fold, and the axis of the breast are drawn. The new
position of the nipple is planned 2 cm lower than the infra-
mammary fold, taking into account the fact that the nipple
will rise more than previously planned as the pillars are
closed. The periareolar marking can be drawn as a mosque
pattern, although we recently do this at the end of the proce-
dure, as described by Hidalgo. The vertical incision lines are
marked by rotating the breast superolaterally and then
D. Ribuffo et al.
superomedially. This maneuver will determine the central
resection of the gland. The vertical lines are joined to each
other 3–6 cm above the inframammary fold. When dealing
with a moderate hypertrophy/ptosis, a “pure” superior pedi-
cle might be chosen (Figs. 2 and 3). Otherwise, a lateral or
medial pedicle (Fig. 4a, b) is designed, depending on the
indications, with a minimum base width of 6–8 cm.
The operation is performed under general anesthesia
with the patient in the supine position and the arms abducted.
The first step is local infiltration along the incision lines and
the base of the breast with 50 cc of 1 % lidocaine with
1:200,000 adrenaline diluted with 50 cc of saline. The pedi-
cle itself is not infiltrated. The nipple-areola complex is
marked with a 45-mm-diameter areola ring. After the
Schwartzman maneuver, the inferior pole breast skin is
undermined, starting below line g-g’ to 1–2 cm above the
inframammary fold. The ideal thickness of the skin flap is
similar to a mastectomy skin flap. A crescentic resection
(Fig. 5a, b) of the inferior pole is performed with an incision
following a line connecting point g to point g’. The distance
between points c and g is usually 6–8 cm. The gland will
easily peel off the inferior surface of the horizontal septum
through an almost avascular plane with the help of a scalpel.
Perforators and nerves can be seen and palpated as small
cords within the septum (Fig. 6).
Depending on the indication, either a lateral or a medial
pedicle is dissected, except for small reductions (Fig. 7a–l)
where we can use the “pure” superior pedicle. A C-shaped
resection of the gland is performed around the pedicle, which
maintains its attachment to the chest wall by means of the
septum at approximately the level of the fifth rib.
3.2 Septum-Based Lateral Pedicle
The breast gland is incised along the medial vertical line
between points d and g’ straight down to the level of the
pectoralis fascia and then extended superiorly toward the
upper edge of the base of the pedicle (point e). The gland
is separated from the rest of the breast by digital dissec-
tion, except for the lateral and central attachments. The
resection is then performed around the pedicle under direct
vision and palpation of the horizontal septum. The gland
excision should be very limited inferior to the pedicle to
avoid damaging the nerves and vessels within the septum.
The septum, which connects the nipple-areola complex
with the thoracic wall, is thereby preserved. The base of
the lateral pillar is rotated superomedially and secured
with 1-0 PDS to the pectoral fascia. This moves the pedicle
centrally to its new position without any tension. Fixation
of the pedicle to the remaining superior breast is unneces-
sary in most cases (Fig. 8a–f).
Vertical Breast Reduction 229

Fig. 1 Markings: figure-of-eight

vertical reduction pattern with
superolateral (a), superior (b),
and superomedial (c) pedicle. a new
upper point position of areola, b new
nipple position, c/d new lower point
position of areola (when sutured)
and upper point of vertical scar,
e/f base of superolateral pedicle,
g/g’ inferior margin of vertical
undermining, h lower point of
vertical scar

3.3 Septum-Based Medial Pedicle
In the septum-based medial mammaplasty technique, the ini-
tial surgical steps are identical up to and including the crescen-
tic excision of the gland inferior to the horizontal septum.
Superior to the septum, the skin is incised from the superome-
dial base of the pedicle laterally and inferiorly. The lateral pil-
lar is then defined bevelling laterally, depending on the desired
amount of resection before cutting down through the septum
at the lateral pillar. The C-shaped resection of the gland is then
completed by continuing the incision around the pedicle back
to the starting point. The pedicle is still attached centrally to
the thoracic wall through the septum, which contains the inter-
costal perforators and nerves. Similar to the lateral pedicle
technique, minimum excision is performed inferior to pedicle.
The lateral pillar is also fixed to the pectoral fascia.
After closure of the periareolar incision (points c and d)
with a deep thin Gore-Tex® suture and a subcuticular 5-0
Monocryl® running suture, the lateral pillar is fixed to the
pectoralis fascia, and the lateral and medial pillars are
230 D. Ribuffo et al.

Fig. 2 (a) Vertical resection

a
with a superior pedicle. (b) The
pedicle is fixed to the pectoralis
muscle. (c) Final closure

c
Vertical Breast Reduction 231

brought together with a few 1-0 PDS stitches. The periareo-

lar incision is closed in three layers. At this point, the deci-
sion is made regarding skin closure pattern.

3.4 Vertical Closure

If a vertical closure pattern is chosen (as in most patients), the

skin is undermined to a limited extent (1–2 cm) to permit clo-
sure with small wrinkles. The deep dermis is sutured with
interrupted figure-of-eight stitches using 3-0 Vicryl to shorten
the length of the vertical incision. A 3-0 Monocryl purse-
string subcuticular suture is placed only at the inferior end of
the vertical wound (2–4 cm length). This permits shortening
Fig. 3 Final result
of the vertical scar and avoids crossing the inframammary
fold with additional vertical skin excision; 6-0 nylon stitches
may be added to smooth out the skin wrinkles.

a b

Fig. 4 Patients marked for a superior (a) and superomedial (b) pedicle in a vertical mammaplasty

a b

Fig. 5 Pattern of breast resection with a superior (a) and superomedial (b) pedicle in a vertical mammaplasty
232 D. Ribuffo et al.

Better definition of the inframammary fold can also be

Clavicle obtained by performing superficial liposuction to the skin
Pectoralis fascia flaps along the inframammary fold and at the inferior end of
Retromammary
the vertical scar.
Pectoralis Major
space
Muscle

5 Postoperative Care
Thoraco-acromial
artery
One suction drain is left in place in each breast, mostly
because we believe it helps in obtaining a better definition of
the inframammary fold. Attention must be paid to place the
drain behind the areola to avoid a retroareolar hematoma. A
gauze dressing is used to cover the incisions, and Micropore
adhesive tape is placed. The drains are removed after 7 days,
4° Intercostal and patients are instructed to wear a sports bra night and day
artery
for 1 month. A tape compressing the inframammary fold is
5° Intercostal then left in place for 1 month.
artery

Fibrous septum
Inframammary
fold ligament
Fig. 6 Wuringer’s septum with the neurovascular supply of the breast
3.5 L or J Closure
The skin excess is shifted laterally at the end of the vertical
scar. The final scar tends to be in a J shape rather than an L
shape. In either case, there is no extension to the medial side of
the breast, where hypertrophic scars occur more frequently.
3.6 Inverted-T Closure
If an inverted-T closure is indicated, it will be designed at the
end of surgery, and any redundant skin in the inferior pole of
the breast is excised. Skin closure is performed with two lay-
ers using interrupted 3-0 polydioxanone in the deep dermis
and a running subcuticular 4-0 Monocryl suture.
4 Liposuction
Liposuction is undertaken after skin closure, if necessary.
We are using it more and more, because we believe it helps
in avoiding the boxy shape, which has been a problem in
some cases. Classical indications include persistent breast
asymmetry, lateral fullness, and axillary tail prominence.
6 Discussion
Before discussing the advantages and the problems related to
vertical (short-scar) breast reduction, we need to highlight
that we do not universally use this technique. Very large
breasts in patients with inelastic skin are not appropriate can-
didates for this operation, as well as patients unable to under-
stand the need for time to stabilize results as well as the
chance for small revisions (puckers, remaining lateral full-
ness, etc.). A well-informed patient is a happy patient.
There are several techniques described for breast reduc-
tion, and there should not be a single technique for every
situation. The literature is full of advocates and opponents of
each technique. Good and average results are attributed to
each specific pedicle. It is difficult, however, to assign pri-
mary responsibility for complications or unsatisfactory
results to pedicle type only. The global outcome in breast
reduction is attributed to many factors, such as skin quality,
the patient’s age and expectations, the degree of ptosis, and
the surgeon’s experience and understanding of breast anat-
omy. Depending on the fundamental principles of plastic
surgery and recent anatomic findings regarding blood and
nerve supply to the breast, the septum-based mammaplasty
has gradually become our favorite technique, as an evolution
from the “pure” superior pedicle vertical mammaplasty.
Our personal odyssey into breast reduction has evolved
from the classical Robbins [2] inferior pedicle technique
(mostly because of the senior author’s experience in
Australia), to short-scar superior pedicle reductions [12, 1].
Vertical scar mammaplasty with a superior pedicle then
became more and more popular with many surgeons because
it provided long-standing good aesthetic results with mini-
mal scars, and we were attracted by this concept at the begin-
ning of the 2000s.
Vertical Breast Reduction 233

However, difficulty in folding the superior pedicle [7,
11] has often been encountered in patients who have glan-
dular or fibrous breast tissue, and this was also our personal
experience. Thinning of the superior pedicle could help to
avoid this problem but compromises the sensitivity of the
nipple-areola complex. Breast reduction with an inferior
pedicle solves this problem, but bottoming out and an
unpleasant shape of the reduced breast are its major
drawbacks.
The concept of pedicle rotation laterally or medially in
breast reduction has been reported by many authors [13,
14] to avoid kinking of the pedicle and venous congestion
and was appealing to us also for the resulting rounded
breast shape. Skoog [15] was the first to describe the lat-
eral dermoglandular pedicle, and many other authors have
modified his technique to a superolateral pedicle with a
more glandular component. Hall-Findlay [13] and others
reported a simplified vertical mammaplasty in which the

a b

c d

e f

Fig. 7 Vertical mammaplasty for breast hypertrophy with a superior pedicle: preoperative (a) and postoperative (b) front views. An average of
450 g per side was removed. The same patient in preoperative (c, e, g, i) and postoperative (d, f, h, l) lateral views
234
g h
i l
Fig. 7 (continued)
superior pedicle was designed superomedially in most of
the cases. However, none of these techniques relied on
specific anatomical structures or on well-established neu-
rovascular bundles. Wuringer et al. [3] reported a new
description of breast anatomy. The authors described a
ligamentous suspension of the breast consisting of a hori-
zontal septum attaching the nipple-areola complex to the
thoracic wall at the level of the fifth rib and connected by
a medial ligament to the sternum and a lateral ligament to
the lateral edge of the pectoralis minor muscle. This hori-
zontal septum includes branches and perforators from the
intercostal, thoracoacromial, and lateral thoracic vessels
and also the lateral branch of the fourth intercostal nerve.
These findings confirmed the anatomical description of
the lateral branch of the fourth intercostal nerve reported
by other authors. The horizontal fibrous septum is a thin
lamina of dense connective tissue that arises from the pec-
toral fascia at the level of the fifth rib and, traversing the
D. Ribuffo et al.
breast from medial to lateral, extends to the middle of the
nipple. It thereby divides the gland into a cranial part and
a caudal part. While heading to the nipple, it also divides
the lactiferous ducts, emptying into the lactiferous sinuses,
horizontally into two even planes of duct openings into
the nipple.
Thus, the horizontal septum separates two anatomical
units of glandular tissue. Using these findings, we adopted
Hamdi’s technique based on the horizontal septum [12]. In
the septum-based mammaplasty technique, the pedicle may
be lateral or medial. The septum-based mammaplasty, which
is an evolution of the centrolateral or centromedial glandular
pedicle techniques, preserves the sensitivity of the nipple-
areola complex after breast reduction and also enhances the
blood supply to the pedicle by including the intercostal per-
forators in the pedicle.
The same authors had shown in a prospective study that
the sensitivity of the nipple-areola complex was maintained
Vertical Breast Reduction 235

a b

c d

e f

Fig. 8 Vertical mammaplasty for gigantomastia with a superolateral pedicle: preoperative (a, c, e) and postoperative (b, d, f) views. An average of
800 g per side was removed

in the immediate postoperative period after a reduction
mammaplasty based on the horizontal septum, and this was
also our personal experience. In contrast, persistent lateral
fullness with lateral pedicle techniques is a drawback. This
can be avoided by basing the lateral pedicle on the sep-
tum (septum-based lateral mammaplasty technique), which
provides a dual blood supply to the pedicle (lateral thoracic
artery and intercostal perforators), so more breast tissue
can be removed laterally with less risk of compromising
the pedicle. However, if the patient initially has extreme
lateral fullness, we would rather choose the medial pedicle
(septum-based medial mammaplasty technique), which
allows a larger and easier resection of the gland laterally.
However, the medial pedicle gives (at least when compared
236
to the septum-based lateral mammaplasty) less breast
projection.
Therefore, septum-based medial mammaplasty is more
suitable for older patients. The septum-based lateral mam-
maplasty technique is more often used in younger patients,
which gives a better outcome in terms of nipple-areola com-
plex sensitivity and breast projection.
Scar-related problems have been our second concern, as
well as excessive skin excision, especially in the first cases
with a high degree of ptosis. The classic skin closure with
only a vertical scar in every patient might result in many
complications, such as wound dehiscence, seroma, hema-
toma, and a high rate of secondary revision. There have been
attempts to decrease these complications by using limited
skin undermining and adding short horizontal scars. Vertical
excision techniques must involve more than a vertical pattern
skin closure. The underlying remodeling of the breast is key
to this concept. Despite the fact that we are very keen on
using vertical and any other short-scar techniques in breast
reduction, breast shaping and modeling are most important
to patients. We believe in the scar-reducing concept, but it
should not be at the cost of a high rate of wound dehiscence
and scar revision.
Adopting an algorithm for choosing the pedicle and the
scar will yield higher patient satisfaction because it allows
the right technique to be selected for the right patient. We
still prefer a vertical scar to close the breast in young patients
or those with dark skin, even with the potential for second-
ary scar correction, because this will result in more a limited
scar, rather than ending up with an inverted-T scar performed
immediately at the end of surgery. Based on a well-
vascularized and constant anatomical structure, the pedicle
is safer, especially in the event of major breast hypertrophy.
In our experience, the septum-based mammaplasty tech-
nique shows advantages over conventional techniques of
breast reduction in terms of pedicle shaping, breast remodel-
ing, and maintaining nipple-areola complex sensation.
The key point of this technique is reduction of the infero-
lateral and central parts of the breast and preservation of the
nipple-areola complex on the horizontal septum using a lat-
eral pedicle (septum-based lateral mammaplasty) or medial
pedicle (septum-based medial mammaplasty). The choice of
the pedicle depends on a number of factors, such as degree of
hypertrophy, position of the nipple-areola complex, lateral
fullness, and age of the patient. In the authors’ experience, a
lateral pedicle offers good projection and maintains nipple-
areola complex sensitivity. It is therefore the favored tech-
nique in younger patients.
A medial pedicle is chosen in cases of extreme breast
hypertrophy with significant lateral fullness. The choice of
D. Ribuffo et al.
skin closure pattern is based on the personal experience
and is related directly to the patient’s characteristics. It is
also determined perioperatively rather than at the time of
preoperative marking. In general, the vertical scar mam-
maplasty is selected in patients younger than 30 years or in
patients with a nipple-to-sternal notch distance less than
30 cm. These patients usually have good skin quality, and
adequate skin retraction is expected. For older patients or
those with a nipple-to-sternal notch distance greater than
30 cm, an L- or J-shaped scar or a short inverted-T scar can
be used if the skin quality is still good. However, a vertical
scar can still be performed for these patients in specific
cases, such as patients who have dark skin or a history of
hypertrophic scarring. An inverted-T scar is more suitable
for patients who have poor skin elasticity associated with
striae.
7 Complications
7.1 Immediate Complications
This includes hematoma, seroma, NAC viability problems,
and infection.
Hematoma has been in our experience a rare occurrence
with the vertical reduction, until we started thromboembolic
prophylaxis and tumescent infiltration. This led to an unac-
ceptable rate of hematomas, some of which had to be surgi-
cally revised. Currently, we do not use any thromboembolic
prophylaxis unless strictly indicated by hematologists, and
we infiltrate the breast avoiding the tumescent-type infiltra-
tion, which obviously can lead to spasm some perforating
vessel from pectoralis major.
Big seromas are very rare in our experience, even with the
use of drains, which we leave for a week. Small seromas are
probably more common, but they usually do not necessitate
any surgery.
Nipple-areola partial or total necrosis is a feared event,
although it is very rare, which luckily we have never had.
In vertical reduction this is still a possible complication,
even if theoretically septum-based mammaplasty maximally
preserves its blood supply. Most vascular problems with the
NAC are caused by venous engorgement, with kinking of the
pedicle being the primary cause. For this reason, we usually
use the medial (lateral) pedicle for most of our gigantomas-
tias, thus limiting the use of a pure superior pedicle to the
treatment of small breast hypertrophy/ptosis with small NAC
descent. In case of clear engorgement, many authors sug-
gest to remove some skin suture, although there is no clear
proof of its utility. This event would probably benefit only
Vertical Breast Reduction
from immediate reoperation, but this is clearly impossible as
it would be too traumatic for the patient.
On the other side, an intraoperative venous stasis can be
obviously treated by modifying the position of the pedicle
and avoiding kinking.
When patients are appropriately selected (BMI, diabetes,
active smoking), infection rarely occurs after a breast reduc-
tion. We routinely use antibiotics after this type of operation,
and we do think that a constricting vertical/gathering closure
can lead to an increased infection rate, so we are very cau-
tious in this setting.
7.2 Late Complications
Late complications are more related to shape than to other
occurrences. However, liponecrosis can be a problem,
because of late calcifications, delayed healing, and long-term
asymmetries. In documented cases of large liponecrosis, sur-
gical removal and breast remodeling are appropriate. In our
experience we had a relative high rate of liponecrosis in our
first cases. We related this event to adipose tissue removal,
and now we use only liposuction as an adjunct to parenchy-
mal resection. With this behavior, our liponecrosis rate has
now dropped.
Shape deformities are more common, and we consider
them more as a related effect than a true complication.
Puckers, underresection, and inframammary fold unadher-
ence can occur even with experienced surgeons. For this
reason, we carefully inform patients of this possibility that
can be easily surgically treated with a small local
revision.
An extremely long vertical scar is, to our opinion, the
result of an inappropriate surgical planning.
8 Informed Consent
As in every plastic surgery operation, informed consent is
essential [16]. However, vertical breast reduction has some
peculiarities that must be well understood by the patient. The
operation is designed to give a long-lasting result with the
benefit of eliminating the horizontal scar, which is truly a
great advantage. On the other hand, patients must well under-
stand the price to pay. This includes a transient boxy shape,
late healing in the vertical scar, and the presence of puckers.
Although this generally settles up with time and rarely
requires revision, puckers can be annoying in the beginning.
With this clearly in mind, the patient will be compliant and
happy in the end.
237
Pearls and Pitfalls
Vertical breast reduction is not a technique for every
patient! In particular, very large reduction in patients
with inelastic skin is not appropriate candidates for this
operation.
Some key points are important to remember:
• Avoid skin undermining.
• Be generous in parenchymal resection: it is the skin
that adapts on the remaining gland, and not vice versa.
• Do not anchor the lower vertical limb to the pecto-
ralis. This usually leads to shape irregularities.
• Perform a no-tension vertical suture.
• Medial pedicle if NAC descent/hypertrophy too big.
References
1. Peixoto G (1980) Reduction mammaplasty: a personal technique.
Plast Reconstr Surg 65:217–226
2. Robbins TH (1977) A reduction mammaplasty with the areola-nipple
based on an inferior dermal pedicle. Plast Reconstr Surg 59:64–67
3. Wuringer E, Mader N, Posch E et al (1998) Nerve and vessel sup-
plying ligamentous suspension of the mammary gland. Plast
Reconstr Surg 101:1486–1493
4. Mc Kissock PK (1972) Reduction mammaplasty with a vertical
dermal flap. Plast Reconstr Surg 49:245–252
5. Berthe JV, Massaut J, Greuse M, Coessens B, De Mey A (2003)
The vertical mammaplasty: a reappraisal of the technique and its
complications. Plast Reconstr Surg 111:2192–2202
6. Lassus C (1996) A 30-years experience with vertical mammaplasty.
Plast Reconstr Surg 97:373–380
7. Lassus C (1999) Update on vertical mammaplasty. Plast Reconstr
Surg 104:2289–2298; (Discussion) 2299–2304
8. Lejour M (1994) Vertical mammaplasty and liposuction of the
breast. Plast Reconstr Surg 94:100–114
9. Hall-Findlay E (2002) Vertical breast reduction with a medially-
based pedicle. Aesthet Surg J 22:185–194
10. Wise RJ (1956) A preliminary report on a method of planning the
mammaplasty. Plast Reconstr Surg 17:367–375
11. Hidalgo D (2005) Vertical mammaplasty. Plast Reconstr Surg
115:1179–1197
12. Hamdi M, Van Landuyt K, Tonnard P et al (2009) Septum based
mammaplasty. A surgical technique based on Wuringer’s septum
for breast reduction. Plast Reconstr Surg 123:443–454
13. Hall-Findlay E (2005) Reduction mammaplasty. In: Nahai F (ed)
The art of aesthetic surgery. Principles and techniques. Quality
Medical Publishing, St. Louis
14. Marchac D, de Olarte G (1982) Reduction mammaplasty and cor-
rection of ptosis with a short inframammary scar. Plast Reconstr
Surg 69:45–55
15. Skoog T (1963) A technique of breast reduction; transposition of
the nipple on a cutaneous vascular pedicle. Acta Chir Scand
126:453–465
16. Monarca C, Tarallo M, Rizzo MI, Scuderi N (2009) Breast lift and
reduction: how we do it. Plast Reconstr Surg 123:1637–1638
 Gigantomastia
Francesco Moschella, Adriana Cordova,
and Francesca Toia
The idea of beauty and “normality” of the breast has undergone
many changes over the years, depending upon customs and
society. To date, breasts are considered normal when symmet-
ric, with a volume ranging between 250 and 400 ml and the
nipple-areola complex situated above the inframammary fold.
Morphologic differences exist between races, which also
depend on weight, age, height, and thoracic structure of the
patient. Therefore, it is rather hard to establish universal ana-
tomic and clinical criteria to mark a clear-cut limit between
normality and hypertrophy of the mammary glands.
However, clinical considerations allow evaluation of the
presence and degree of hypertrophy in a particular patient. In
this regard, clinically important features are:
• Breast volume
• The distance between the middle point of the clavicle and
the nipple-areola complex
• The distance between the inframammary fold and the
nipple-areola complex
In one of the most accepted classifications, considering
standard breast volume as ranging between 250 and 400 ml,
hypertrophy is defined as mild for volumes between 400 and
600 ml, moderate between 600 and 800 ml, severe between
800 and 1,000, and gigantomastia over 1,000 ml (Fig. 1) [6].
A distance of 16–21 cm between the midclavicular point
and the nipple-areola complex is considered “normal,” but
this value is considerably influenced by patient height. The
distance between the nipple-areola complex and the inframa-
mmary fold is usually 5–8 cm.
F. Moschella, MD (*)
Dipartimento di Discipline Chirurgiche e Oncologiche,
Università di Palermo, Palermo, Italy
e-mail: franzmoschella@libero.it
A. Cordova, MD • F. Toia, MD
Sezione di Chirurgia Plastica e Ricostruttiva, Dipartimento di
Discipline Chirurgiche e Oncologiche, Università di Palermo,
Palermo, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_18
Macromastia or mammary hypertrophy is a deforming,
disabling, and painful condition characterized by an enlarge-
ment of various degrees of one or both breasts. Besides being
a significant aesthetic defect, this condition causes physical
and psychological problems.
Clinical manifestations associated to mammary hypertro-
phy are:
• Intertriginous lesions induced by friction of the breast
against the thorax and by the bra straps on the shoulders;
these lesions worsen with perspiration, which predisposes
to infections by Candida, further increasing irritation of
reddened areas.
• Spinal deformity, with progressive kyphoscoliosis or dor-
sal kyphosis with attenuation of lumbar lordosis.
• Deformity of sternum-clavicular bony structures, with
subsequent headache, neck, and shoulder pain, hand par-
esthesia, and breathing difficulties.
• Sleep disorders and difficulty in dressing and accomplish-
ing certain movements.
An ulnar neuropathy has also been described in women
with severe breast hypertrophy, who report paresthesia in the
ulnar nerve territory.
Moreover, psychological problems can negatively influ-
ence social and sexual life. Reduction mammaplasty has to
be considered, in such a clinical picture, the best therapeutic
approach for these patients.
1 Normal Anatomy
The breast is a pair and symmetric skin relief situated on the
anterior surface of the thorax, between the third and the sev-
enth rib, extending from the parasternal line to the middle
axillary line. The nipple should lie above the inframammary
fold and is usually at the level of fourth rib.
The mammary gland, being derived from the ectoderm, is
contained in the superficial layer of the subcutaneous tissue,
239
240 F. Moschella et al.

a b

c d

e f

Fig. 1 (a, b) Moderate breast hypertrophy. (c, d) Severe breast hypertrophy. (e, f) Gigantomastia

between the superficial fascia and the skin. It is anchored to A horizontal fibrous septum originates from the pectoral fascia
the pectoralis major fascia by the suspensory ligaments first along the level of the fifth rib, dividing the mammary gland in
described by Cooper in 1840, which run from the deep fascia a cranial and a caudal part. It acts as a suspensory system and
throughout the parenchyma to attach to the dermis of the skin. as a guiding structure for vascular and nerve supply.
Gigantomastia
1.1 Vascular Anatomy
The blood supply to the breast relies on two main pedicles:
the superolateral pedicle of the external mammary artery
(branch of the lateral thoracic artery) and the glandular
branches of the thoracodorsal artery and the internal pedicle
of the internal mammary artery, with its perforators from the
second to sixth interspace. Their superficial branches anasto-
mose in the subdermal plexus, supplying the breast skin.
A large perforator of the internal mammary artery emerges
from the second or third interspace, running about 1 cm deep
to the skin and supplying a superior pedicle for the nipple-
areola complex [15]. Perforators from the third to sixth inter-
space also present a superficial course and supply a medially
based pedicle. The lateral pedicle relies on the lateral tho-
racic system that is usually found 2 or 3 cm deep to the skin
at the level of the inframammary fold.
1.2 Innervation
The sensory innervation of the breast is mainly derived from
the anterolateral and anteromedial branches of thoracic inter-
costal nerves T3–T5.
The innervation of the nipple-areola complex depends on
the lateral branch of the fourth intercostal nerve, with its
superficial and deep branches. The first one supplies a lateral
pedicle, while the deep branch can sometimes be preserved
with an inferior or central pedicle. The anterior branch of the
third intercostal nerve also contributes to the sensitivity of
the nipple-areola complex; it takes a superficial course within
the subcutaneous tissue and terminates at the medial areolar
border [17].
2 Pathogenesis
The breast is the target organ for numerous hormones, which
are responsible for mammogenesis, lactogenesis, and
galactogenesis.
Some authors claim that alterations in endocrine arrange-
ment concerning estrogens, progesterone, prolactin LH, and
FSH could represent the “primum movens” of mammary
hypertrophy.
Endogenous hormone stimulation seems to play an
important role in juvenile and pregnancy-induced mammary
hypertrophy, in which a rapid and massive enlargement of
the breasts occurs. Subsequent pregnancies are likely to
cause further recurrence, once pregnancy-induced mammary
hypertrophy has occurred.
Yet in the majority of patients, it is not possible to identify
a precipitating cause.
241
The main pathogenetic hypotheses of severe juvenile and
pregnancy-induced mammary hypertrophy are:
• An increase in serum level of estrogens, prolactin, proges-
terone, HGC, or HLP that could be associated with anom-
alies in ovarian function or to malignancy (ovarian,
adrenal, pituitary)
• An increase in free estrogen circulating levels, due to
reduction of sex binding globulin
• Alterations in hepatic hormone catabolism
• An increase in breast hormonal receptor sensibility or
number, with normal serum hormone level
Hyperprolactinemia has been associated with mammary
hypertrophy, but its exact role is not absolutely clear. Not all
patients with hyperprolactinemia present with breast hyper-
trophy, but patients with pregnancy-induced gigantomastia
usually respond well to high dose of an anti-prolactin agent
such as bromocriptine. In contrast, breast enlargement may
not be arrested in patients with juvenile hypertrophy and
hyperprolactinemia.
Another reported association is between hypercalcemia
and juvenile and pregnancy-induced hypertrophy, which has
been attributed to an excessive production of PTHrP (para-
thyroid hormone-related protein). The reason for the increase
in PTHrP production that accompanies pregnancy-induced
hypertrophy is not yet known [9].
In favor of the hypothesis of an altered hepatic metabo-
lism, one case of macromastia in an infant with Alagille’s
syndrome has been reported in literature, in which mam-
mary hypertrophy was directly correlated to alterations in
the hepatic metabolism of estrogens, rather than to their
hyperincretion under a gonadotropic stimulus, to the aro-
matization of androgens, or to central nervous system
abnormalities [1].
Only a few studies exist on juvenile hypertrophy, while
much more data are available about pregnancy-induced
mammary hypertrophy [3].
To date no study has confirmed the more accredited
hypothesis, that of an increased responsiveness of
breast tissue to circulating hormones (receptor
hypersensibility).
In the literature, several cases of mammary hypertrophy
have been reported as adverse effect of a pharmacological
treatment. Some authors reported the onset of gigantomastia
after prolonged therapy with indinavir, a protease inhibitor,
used in the treatment of HIV infection.
An HIV-positive woman, 1 month after beginning a
triple therapy with lamivudine, stavudine, and indinavir,
presented a rapid and progressive increase in breast vol-
ume that regressed after discontinuation of indinavir
alone [8].
242
The importance of the role of indinavir for this particular
case of gigantomastia is confirmed by several considerations:
• Serum level of estrogens or prolactin is within the normal
range.
• Indinavir frequently causes nonspecific morphological
changes of some body segments (e.g., abdominal
adiposity).
• Discontinuation of indinavir alone, while receiving the other
drugs, leads to a complete remission of the clinical picture.
Another rare condition is gigantomastia in patients with
rheumatoid arthritis, receiving D-penicillamine. The first
case was described by Desai in 1973.
It is likely that by reducing circulating levels of sex
hormone-binding globulin, D-penicillamine induces an
increase in serum levels of estrogens, thereby causing mam-
mary hypertrophy, or possibly by chelating zinc ions, breast
tissue is sensitized to the action of prolactin or other hor-
mones. A direct action on the mammary gland is also to be
considered. Discontinuation of D-penicillamine leads to an
arrest in breast enlargement [14].
A rare cause of mammary hypertrophy is systemic lupus ery-
thematosus (SLE). In 1960 Shelley described a case of severe
bilateral mammary hypertrophy in a young woman with posi-
tive SLE tests, diffuse annular erythema, and melanodermia.
Propper reported the case of a woman with SLE with dis-
ease flare during pregnancy and breast hypertrophy compli-
cated by severe necrotic and ulcerated skin lesions, probably
attributable to cutaneous vasculitis. This condition resolved
almost completely after delivery under steroid therapy [13].
Both juvenile and pregnancy-induced mammary hyper-
trophies related to SLE have unclear etiologies; it is likely
that SLE may induce the production of substances that
directly or indirectly by mimicking the action of estrogen or
other growth factors cause an increase in breast volume [5].
Obesity plays an important role in the pathogenesis of
breast hypertrophy; breast volume increases in all over-
weight conditions, and it is not surprising that obese patients
represent 2/3 of macromastia cases.
In the literature it is reported that the hypertrophic breast
is composed primarily of adipose and fibrous tissue, while
the glandular component remains essentially stable.
Lejour reported an average of 48 % fat by weight in breast
reduction specimens. She also observed that the body mass index
has more influence than age on the amount of breast fat [10].
This pathologic finding has also been highlighted by
Strömbeck, who proposed the term “macromastia” for
patients requiring reduction mammaplasty, considering
incorrectly a diagnosis of “mammary hypertrophy” [16].
Several authors confirmed the importance of the fat com-
ponent in the enlarged breast and reported their experience
with liposuction as an integral part of the surgical treatment
of macromastia.
F. Moschella et al.
3 Treatment
Reduction mammaplasty is the best therapeutic approach for
patients with mammary hypertrophy, for both physical and
psychological reasons. Its goal is to achieve a reduction of
breast volume while maintaining vascularization and inner-
vation of the nipple-areola complex and limiting scars [7].
The first attempts at reducing breast volume were purely
functional, and it is only in the last century that aesthetic
considerations were taken into account.
Up until 1960, techniques of breast reduction were not
safe, because of extensive skin and glandular undermining.
In 1957, Arie realized that it was preferable to avoid any
undermining between the skin and gland. In 1963, Skoog
proposed an inferoposterior resection and the transposition
of the nipple-areola complex on a laterally based dermal
pedicle flap, laying the basis for the development of modern
reduction mammaplasty.
Since then, many surgical techniques have been created,
with an increasing interest in reducing scars’ length [4, 11].
The choice of technique depends on the size of the
breast, the degree of ptosis, the patient’s goal, and sur-
geon’s preferences. The two main decisions that confront
the surgeon are the choice of incision pattern and the choice
of pedicle type, which are, for the most part, independent
variables.
Different pedicle nipple-areola flaps can be employed,
including a superior pedicle, an inferior pedicle, a vertical
bipedicle, a central mound pedicle, and a lateral or a supero-
medial pedicle [2].
The incision pattern usually consists of a vertical or an
inverted-T scar, which can be applied to any pedicle type,
with the advantage of reducing scars’ length.
The choice of the pedicle usually depends on the need for
elevation of the nipple-areola complex and the desire to pre-
serve sensory innervation or lactation.
4 Authors’ Technique (Fig. 2) [12]
Accurate skin markings are made preoperatively, which basi-
cally refer to Lejour’s vertical scar technique; for this pur-
pose, the jugular notch is marked, together with two points
on the clavicle 5–6 cm each side of it. A line passing through
the nipple is drawn from these points to the inframammary
fold (breast meridian).
The new nipple-areola complex position is drawn at the
intersection of the inframammary fold and the breast merid-
ian that usually correspond to a distance of 19–22 cm from
the jugular notch, varying with patient height. The areola
region is marked with circular patterns on photographic film,
obtaining a periareolar circumference of between 14 and
18 cm. In case of gigantomastia, an elliptical pattern of
18 cm is used.
Gigantomastia 243

a b

c d

e f

g h

Fig. 2 Authors’ technique. (a) Skin markings. (b) Preoperative view of the patient. (c) The superior pedicle. (d) Wedge resection of the inferior
pole. (e) Suture of the lateral pillars. (f) Immediate postoperative view. (g, h) One-year postoperative view of the patient

The lateral margins of the area to be de-epithelialized are
marked by turning the breast in a clockwise direction and
counterclockwise, respectively. The lower edge of the mark-
ing is obtained by combining the two lateral branches with a
circular arc passing 2–4 cm above the fold.
The lower breast quadrants are then infiltrated with saline
and adrenaline 1:100,000. Next, de-epithelialization of the
upper portion of the marked periareolar area is performed
and extended about 4 cm inferiorly in order to maintain the
arterial and venous periareolar network. The skin is then dis-
sected medially and laterally, as necessary, and the dissec-
tion is carried down to the fascial plane.
At the fascial pre pectoral plane the breast is separated
from the fascia of the pectoral muscle along a wide central
tunnel of about 8 cm, and resection of the inferior pole and
of a wedge below the de-epithelialized area is performed.
The pedicle nipple-areola flap is then anchored high to the
chest, and the two remaining medial and lateral pillars are
244 F. Moschella et al.

a b

c d

Fig. 3 A 25-year-old patient. (a, b) Preoperative view. (c, d) One-year postoperative view (authors’ technique)

a b

c d

Fig. 4 A 28-year-old patient. (a, b) Preoperative view. (c, d) Six-month postoperative view (authors’ technique)

sutured to each other in order to reassemble the cone of the
breast. At this point, excess skin is evaluated, and the direc-
tion of the scar is decided upon.
The remaining skin is defatted very carefully.
We found that in young patients with good skin elasticity
and for resection of up to 1 kg, a simple vertical scar can be
used.
The wrinkled appearance of the scar resolves within a few
weeks. In patients with flaccid skin and for resections of over
1 kg with elevation of the nipple-areola complex over 10 cm,
sometimes it is aesthetically more convenient to make an L
or T-inverted scar.
The final direction of the scars and the quantity of skin to be
removed are decided on a case by case basis (Figs. 3 and 4).
Gigantomastia 245

References 9. Khosla S, van Heerden JA, Gharib H et al (1990) Parathyroid

hormone-related protein and hypercalcemia secondary to massive
mammary hyperplasia. N Engl J Med 322:1157
1. Arscott GD, Craig HR, Gabay L (2001) Failure of bromocriptine
10. Lejour M (1997) Evaluation of fat in breast tissue removed by verti-
therapy to control juvenile mammary hypertrophy. Br J Plast Surg
cal mammaplasty. Plast Reconstr Surg 99:386–393
54:720–723
11. Materasso A (2000) Suction mammaplasty: the use of suction
2. Cordova A, Corradino B, Maltese G, Napoli P, Graziano A,
lipectomy to reduce large breasts. Plast Reconstr Surg 105:
Moschella F (2000) Mastoplastica riduttiva a peduncolo superiore
2604–2607
nelle gigantomastie. Contraccezione Fertilità Sessualità 27:257
12. Moschella F, Cordova A, D’Arpa S (2002) Mastoplastica additiva,
3. Corriveau S, Jacobs JS (1990) Macromastia in adolescence. Clin
mastopessi e mastoplastica riduttiva. Med Est Chir Plast Est 241–254
Plast Surg 17:151–160
13. Propper DJ, Reid DM, Stankler L, Eastmond CJ (1991) Breast vas-
4. Courtiss EH (1993) Reduction mammaplasty by suction alone.
culitis in association with breast gigantism in a pregnant patient
Plast Reconstr Surg 92:1276–1284
with LES. Ann Reumatic Dis 50:577–578
5. Cruz-Korchin N, Korchin L, González-Keelan C, Climent C,
14. Rooney PJ, Cleland J (1981) Successful treatment of
Morales I (2002) Macromastia: how much of it is fat? Plast Reconstr
D-penicillamine-induced breast gigantism with danazol. Br Med
Surg 109:64–68
J 282:1627–1628
6. Dancey A, Khan M, Dawson J, Peart F (2008) Gigantomastia–a
15. Schelnz I, Kuzbari R, Gruber H, Holle J (2000) The sensitivity of
classification and review of the literature. J Plast Reconstr Aesthet
the nipple-areola complex: an anatomic study. Plast Reconstr Surg
Surg 61:493–502
105:905–909
7. Gonzalez F, Walton RL, Shafer B, Matory WE Jr, Borah GL (1993)
16. Strömbeck JO (1964) Macromastia in women and its surgical treat-
Reduction mammaplasty improves symptoms of macromastia.
ment: a clinical study based on 1042 cases. Acta Chir Scand
Plast Reconstr Surg 91:1270–1276
341(Suppl):1
8. Herry I, Bernard L, de Truchis P, Perrone C (1997) Hypertrophy
17. Würinger E, Mader N, Posch E, Holle J (1998) Nerve and vessel
of the breast in a patient treated with indinavir. Clin Infect Dis
supplying ligamentous suspension of the mammary gland. Plast
25:937–938
Reconstr Surg 101:1486–1493
 Aesthetic Surgery for Breast Asymmetry

L. Franklyn Elliott and J. Nicolas Mclean

Breast asymmetry is a frequent and difficult problem for in order to make the appropriate surgical decision. These
the patient and for the plastic surgeon. Asymmetry of the considerations include the patient’s age, the patient’s matu-
breasts can be either congenital or acquired and includes rity, the recent breast growth history, the number of children
breast mound volume, inframammary fold position, pres-
ence of base diameter constriction, and asymmetries of the
nipple/areolar complex size and position [1, 2]. Acquired
breast asymmetry can be secondary to previous aesthetic
surgery or secondary to previous breast reconstructive sur-
gery. This chapter will concentrate on both congenital
breast asymmetry and acquired breast asymmetry second-
ary to previous aesthetic surgical procedures (Figs. 1 and
2). While aesthetics are enormously important to the suc-
cess of breast reconstruction, breast reconstruction cases
will not be considered here.
Congenital breast asymmetry can be asymmetry of size
or shape or, of course, both. Poland’s syndrome, which is
the congenital absence of a part or the entire breast, is a
relatively separate issue, as it requires more extensive sur-
gery over a longer period of time. A thorough discussion of
this surgical problem requires a chapter unto itself. Thus,
consideration of this syndrome will not be part of this Fig. 1 Congenital breast deformity (tuberous breast)
chapter.
Congenital asymmetry with regard to size is usually due
to decreased growth of one breast, but there can be infinite
variables in the presentation of this problem. Conversely, the
breast could also be too large on one side compared to the
smaller side that is acceptable to the patient. The first consid-
eration in this situation is to determine which size the patient
prefers and, if neither, what size she would like to be. At this
point, a number of considerations must be brought into play

L.F. Elliott, MD (*)

Atlanta Plastic Surgery, Emory University Partner,
Atlanta, GA, USA
e-mail: frank3668@mindspring.com
J.N. Mclean, MD
Private Practice, Conyers, GA, USA Fig. 2 Acquired breast deformity

© Springer Berlin Heidelberg 2016 247

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_19
248
the patient has and expectations for future children, expecta-
tions of results, family history of breast cancer, and previous
breast pathology. The age and mental maturity of the patient
are important in deciding the timing for the surgical proce-
dure. If the patient is unable to verbalize what she would like
to achieve or if she is too immature to be examined, it is
probably a good idea to give the patient a little more time.
There is nothing set in stone about age 18, but in general, we
prefer to not operate on patients under 18 and to consider
surgery thereafter. It must be said, however, that for severe
deformities, operations can be performed after breast devel-
opment and asymmetry have occurred. Of course, it must be
emphasized to the patient and her parents that subsequent
procedures will most likely be needed.
The number of children the patient has and expectations for
future children should be taken into consideration, chiefly with
regard to breast feeding and subsequent breast changes. If the
patient has had all her children, obviously the breast changes
and concern for breast feeding are not a factor. On the other
hand, if a patient is nulliparous and expects to have children,
both these factors should be discussed in depth. It is likely that
most patients after breast procedures will be able to breast-feed
[3–5]. However, there is a certain percentage that cannot, and
this should be discussed with the patient preoperatively.
Expectations of results, as with any aesthetic surgery,
should be appropriate and in concert with what the surgeon
thinks he or she can achieve. In this situation, a patient who
cannot seem to realize that breasts will sag over time or who
desire overly large breasts should be counseled with care and
perhaps rejected until their expectations are more realistic.
Most complications can be avoided with careful planning
and decision making. Primary augmentation demands a care-
ful evaluation of the breast morphology and chest wall anat-
omy [6]. A family history of breast cancer does not preclude
breast surgery, but, again, a thorough discussion of this sub-
ject is appropriate. Multiple studies support the conclusion
that silicone and saline breast implants do not delay the
detection or cause breast cancer [7–11], but the submuscular
position would most likely be preferred in these patients [12,
13]. Implants however appear to facilitate tumor detection on
physical examination [13]. Patients with history of previous
benign or malignant breast pathology may require proce-
dures such as multiple biopsies and may put the breast
implants at risk. This should be explained to the patient,
although radiologists have become increasingly capable of
carrying out breast biopsies without injuring implants.
If the patient considers one breast too large and the oppo-
site breast is an appropriate size, reduction of the larger
breast is performed [14]. After all the above considerations
have been discussed and the timing is appropriate for the
individual patient, an operation can be decided upon.
Certainly, breasts can grow after surgery, but this is relatively
uncommon, particularly after patients are 18 years or older.
L.F. Elliott and J.N. Mclean
As mentioned above, pregnancy can certainly change breasts
by making them larger or smaller, and this may vary in the
situation of congenital breast asymmetry. Surgery before or
after the pregnancy is not contraindicated in case of signifi-
cant breast asymmetry.
The shape of the desired breast determines the type of
reduction pattern that is used. For instance, the circumareolar,
or inverted-T operation, yields a flatter, broader breast, while
the vertical pattern yields a more projecting, narrowly based
breast. The technique for the circumareolar reduction as
described by Goes [15] (but without mesh) is our preferred
method. However, it is also somewhat limited by size con-
straints. The operation is done by creating a circle, the point
of which is 1.0–2.0 cm above the ideal nipple location.
A circle is then drawn from this area around the underlying
nipple/areolar complex (Figs. 3 and 4). This incision is then
made and the entire breast is undermined. A specimen is
removed from the 11 to the 1 o’clock position, plicating the
breast tissue to itself to restore the upper pole of the breast
and even advancing the upper pole cephalad. An additional
specimen can be removed from the 5–7 o’clock position infe-
riorly, plicating the inferior pole to itself, achieving more pro-
jection, and tightening the lower pole of the breast. The
inferior dissection site is drained, and the circumareolar clo-
sure is done using a permanent braided suture to prevent dila-
tion of the nipple/areolar complex postoperatively. Reductions
are usually limited to 200–300 g using this technique. We
reserve the choice for the circumareolar breast reduction for
those patients whose sternal notch to nipple distance is no
greater than 24.0 cm. This is because the circumareolar design
must be brought down to a 38–42 mm circle, which creates a
large amount of skin gathering if the distance from the sternal
notch to the nipple is greater than 24.0 cm.
The limited scarring for the circumareolar approach is
obviously preferred, but one must be aware that the skin
gathering and pleating can be significantly undesired side
effects and may require conversion to the vertical or at the
least a secondary scar, revision procedure.
For the larger, more ptotic breast, the vertical technique is
used, as described by Lassus [16]. Using this technique,
more breast tissue can be reliably removed, although the
excision of tissue is usually not carried above 500–600 g.
Closing the lower pillars using permanent sutures narrows
the breast and gives increased anterior projection, thus mak-
ing a more conical-shaped breast (Figs. 5 and 6). This tech-
nique may or may not better match the opposite breast,
depending on the shape of the opposite breast. It is also
important to anticipate some sag of the vertical technique, as
this almost predictably occurs in every case. Thus, what one
sees on the operating room table is not what will be seen 3
months or 6 months after the surgical procedure.
The inverted-T incision is rarely used in correcting con-
genital asymmetry. Only the very largest, most ptotic breast
Aesthetic Surgery for Breast Asymmetry 249

Fig. 3 (a, b) Circumareolar

technique
a b

a b

Fig. 4 Circumareolar mastopexy. (a) Preoperative photo; (b) 1 week postoperative; (c) 1 year postoperative
250 L.F. Elliott and J.N. Mclean

a b

c d

Fig. 5 Vertical mastopexy technique. (a) Markings; (b, c) flap dissection; (d) pillars closed

would the inverted-T be considered [17]. It is important to
try to avoid scarring as much as possible and limit the proce-
dures to either the circumareolar or vertical approach. In this
case, the effort would be to design initially a vertical proce-
dure, which could then be converted if there is significant
extra skin inferiorly along the inframammary line.
If the larger breast is preferred in the situation of congeni-
tal breast asymmetry, an augmentation of the smaller breast
will generally suffice. If there is a scant amount of breast
tissue on the breast to be augmented, we prefer to use a gel
implant and almost always place the implant behind the mus-
cle. The effort is to increase the size of the smaller breast to
match the larger breast, hopefully without the need for a pro-
cedure on the larger breast. Placing the implant behind the
muscle covers the implant with another layer of tissue and
separates the implant from the breast tissue, which may be
helpful in imaging, as indicated, and may be associated with
softer breasts as compared with submammary placement.
However, at times, the larger breast is ptotic or has a large
areolar size; both of which would be modified to achieve
symmetry with the augmented breast.
Shape problems with regard to congenital asymmetry
almost always have to do with differences in the inferior
pole of the breast. Commonly, this is called a constricted or
Aesthetic Surgery for Breast Asymmetry 251

a b

c d

Fig. 6 Vertical mastopexy. (a, b) Preoperative photo and markings; (c) preoperative view; (d) 1 year postoperative picture

tuberous breast. This entity is strongly associated with breast
asymmetry as demonstrated by De Luca-Pytell et al. [18].
Unfortunately, in these situations, neither breast is typically
acceptable to the patient, and the patient almost always wants
the breasts to be somewhat larger. The key to this operation
is extensive release of the inferior breast skin in the subcuta-
neous plane and the “unfurling” of the breast tissue that is
constricted into the central portion of the breast [19, 20]
(Figs. 7 and 8). On the other hand, the skin usually responds
to the outward thrust of the breast implant over time, and the
skin is, thus, generally not an issue as long as it is released
with extensive dissection. This condition can be found in an
asymmetric manner in both breasts; thus, the breast tissue on
one side may need to be treated more aggressively than that
on the opposite side. Similarly, the skin may be tighter on
one side than the other.
The “unfurling” of the constricted breast tissue is done by
releasing this breast tissue from the underlying pectoralis
major muscle and back cutting the breast tissue so that it
unfurls and fills the lower pole of the breast. Once this is
completed and breast tissue has filled to whatever extent is
possible in the lower pole of the breast, the submuscular dis-
section can be performed. Once the submuscular pocket is
fully dissected, the implant is inserted. This can be either a
saline or gel implant, depending on the amount of overlying
breast tissue. If there is adequate breast tissue (200 g or
more), either type of implant can be used. We prefer a smooth
implant, but a textured implant also works well in this situa-
tion. Sometimes, the submuscular placement can lead to
constriction of the lower pole of the implant. In this case, we
have no reluctance in doing an inferior division of the muscle
and find that the implant ultimately rests with the lower pole
in the submammary position and the upper pole in the sub-
muscular position. It should not be necessary to tack down
the unfurled breast tissue into the lower pole, but if it does
not fill the lower pole as would be liked, this can be done.
It is rarely necessary to use local flaps on the inferior pole,
as this constricted skin almost always releases over time with
pressure from the underlying implant. The implants should
be placed in the proper position at the time of the operation
and should not require postoperative banding to force them
into position. Postoperative dressings are minimal, with only
skin tape on the periareolar skin incision.
A division has been made between shape and size for the
purpose of discussion; however, patient presentation is
almost always a combination of shape and size. All patients
are sensitive about breast asymmetry. It is interesting that
some patients will tolerate a great deal of breast asymmetry
that occurs over time after surgery and others have a great
intolerance to any asymmetry and will seek multiple operations
252 L.F. Elliott and J.N. Mclean

Fig. 7 (a) Preoperative views; (b) “unfurling”; (c) postoperative views

Aesthetic Surgery for Breast Asymmetry 253

a b

Incision

Retrograde incision

Isolation of the skin at the subcutaneous plane

c

Hypoplastic
breast

Continue to the posterior mammary parenchyma reaching

towards the nipple

f
d
The caudal part of the breast parenchyma expands
and goes to fill the lower pole of the breast

The mammary parenchyma

is cut in a horizontal plane

If necessary, add the

prosthesis, positioning it
behind the muscle (A),
advance in the position (A')

Fig. 8 Surgical technique to “unfurl” the breast tissue

254
to maintain as much symmetry as possible. Advising these
patients on timing and the number of operations can be
sometimes difficult. It is probably worthwhile to not do any
surgical procedures within a year after the previous surgery
except in the presence of significant seroma, hematoma, or
asymmetry.
Even fairly marked differences at 1 month after surgery
can become quite a bit less with time when the breasts are
allowed to mature postoperatively. Certainly, there are those
patients for whom the small change they desire is actually
not achieved by the surgeon. These patients require extensive
counseling with regard to their expectations.
1 Asymmetry Due to Previous Aesthetic
Surgery
Asymmetry due to previous aesthetic surgery is generally
related to problems due (Fig. 9) to capsular contracture
(Fig. 10), persistent breast ptosis (Fig. 11), or size asymme-
try [21]. Capsular contracture, although somewhat less com-
mon today than in the 1980s or 1990s, still occurs and vexes
both the patient and the surgeon [22, 23]. Capsular contrac-
ture can also be ascertained with a mammogram that has
revealed a possible leaking implant [24]. This gives both the
surgeon and the patient even more indication for reoperation,
especially if the implant is greater than 10 years old. Once
one has decided on the desired size in consultation with the
patient, a strategy for the capsular contracture treatment can
be decided upon. If the implant and capsule are submam-
mary, implant removal and submuscular conversion are an
excellent choice. There is usually no need to remove the cap-
sule itself unless it is calcified and has eggshell-like findings
within it [25]. Unless the capsule itself deforms the breast,
without an implant inside the capsule, the capsule causes no
significant problem.
If the implant is submuscular and there is significant cap-
sular contracture, the implant can either be converted to a
submammary position or a “neo pocket” can be created deep
to the muscle but superficial to the underlying capsule
(Fig. 10). In order to perform this dissection, one needs a
capsule that has some thickness to it, as very thin capsules
are very difficult to dissect away from the overlying muscle.
On the other hand, significant capsular contractures are usu-
ally associated with thicker capsules. We usually prefer to
not employ the submammary conversion of a submuscular
capsule because the breast has been thinned over time, and
placing the implant underneath the overlying thin tissue
often yields palpable edges of the implant or even rippling in
the superior or lateral regions of the breast.
Other capsule problems include the malposition of
implants in any direction. Our preferred technique has been
L.F. Elliott and J.N. Mclean
to employ local capsulectomies in the position where the
implant is out of position, suturing the new fresh edges of the
capsule together using permanent braided suture [26]. This
technique, while successful in 60–80 % of cases, is not
always successful in the medial, inferior, or lateral regions
due to continued gravitational pressure of the implant against
the suture lines with time. Thus, we add acellular dermal
matrix (ADM) to this capsulorrhaphy technique to give addi-
tional structure to the repair [27, 28], and this seems to
decrease the incidence of capsule contracture [29]. The
ADM is sewn in with the two fresh edges of the capsule
down to the chest wall to give strong support and attachment
to the new capsular location. All of these capsulorrhaphy
procedures are coupled with postoperative management
which includes taping with Medipore tape (3 M St. Paul,
MN, USA) inferiorly and laterally for 2 weeks after the cap-
sulorrhaphy (Fig. 9). In addition, the patient is instructed to
wear a bra 24 h a day 7 days a week for 1 month postopera-
tively. The feeling is that if we can control and hold the breast
for 6 weeks, the scarring will be strong enough to prevent the
unwanted migration of the implant in the wrong direction.
Breast ptosis is, of course, a continuing problem and a
common one after previous aesthetic surgery. This can occur
after breast augmentation or after mastopexy with or without
augmentation. Breast ptosis is generally treated with the verti-
cal mastopexy technique as described by Lassus [16, 30] and
Lejour [31] above. This is a powerful lift that narrows and
gives good projection to the breast, which is appreciated by the
patient. Recovery is relatively easy in the secondary surgical
procedures. However, we do employ taping to support the lift
for 2 weeks and wearing a bra for 1 month thereafter to encour-
age the assistance of scarring to establish and maintain the lift.
Size asymmetries can occur due to unequal growth of the
breasts, the late development of a seroma around the
implant, or the decrease in breast size after several pregnan-
cies. It is important to assess the remaining breast tissue and
the implant size. If the patient would like smaller implants,
capsulorrhaphy may be needed and is performed as
described above [26]. On the other hand, if an increase in
breast size is desired, along with a breast lift, one must be
careful to not remove too much skin inferiorly with the ver-
tical technique, such that the closure would be too tight
along the inferior vertical line. One must mark the proposed
skin excision inferiorly in a conservative manner with the
idea that added skin can be removed at the end of the proce-
dure if shape warrants this.
Nipple/areolar displacement is not uncommon in patients
with long-standing breast asymmetry after placement of
breast implants [32]. The nipple/areola complexes can be
moved medially or laterally using the vertical technique at
the time of the breast lift. Movement of the nipple/areolar
complex can also be done using the inverted-T approach, but,
Aesthetic Surgery for Breast Asymmetry 255

a b

Fig. 9 Acquired breast asymmetry. (a) Preoperative view; (b, c) postoperative views

a b

Fig. 10 (a) Capsular contracture; (b) neo pocket

256
Fig. 11 (a) Continued ptosis; (b) postoperative view
again, we prefer to avoid that scar when possible. Moving
the nipple/areolar complex medially and laterally using the
circumareolar approach is not as predictable as using the ver-
tical technique. At times, the nipple/areolar complex can be
out of proper location so much that it should be moved as an
island to an entirely different position, usually more medi-
ally on the breast. This technique involves additional scar-
ring laterally, which is not particularly attractive to the
patient, but may be tolerated if breast shape and the nipple/
areolar complex are distorted.
In summary, aesthetic breast asymmetry issues can be
challenging. The presentation of the asymmetry is almost
infinite, and the surgeon must have a host of techniques avail-
able for consideration in order to achieve the best result. Even
the most experienced surgeon using the most predictable
L.F. Elliott and J.N. Mclean
technique may have to perform secondary procedures to
achieve the result the patient desires. However, with careful
preparation and execution of the surgery, near symmetry can
be obtained in the first surgery, if not, then after the second
much smaller operation. Breast asymmetry is a humbling
challenge for aesthetic plastic surgeons. It is important to
keep this in mind with each and every patient we see with
these difficult problems.
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33:591–596
 Tuberous Breast: Different
Morphological Types
and Corresponding Correction Flaps
Egle Muti
1 Introduction
The tuberous breast is a denomination not easy to define
because it is difficult give a single, clear, and simple defini-
tion. When we talk about tuberous breasts we enter into a
vast realm of different definitions, anatomical characteris-
tics, and correction techniques. Among the numerous defini-
tions used to describe these malformations are tuberous
breast, tubular breast, hypoplasia of the inferior pole, con-
stricted inferior pole, snoopy breast, domed nipple, and
intra-areolar herniation [1].
Along with this vast and confusing spectrum there seems
to be a diagnostic confusion corresponding to the diverse
anatomical-morphological typology. As a consequence,
there is an unclear embryological explanation and some con-
fusion concerning the possible surgical choices, which are
not always adaptable to the various anatomical-morphological
types.
These malformations represent a sizable surgical chal-
lenge even to the most skilled surgeon. To achieve an optimal
result, a careful preoperative analysis is always required. To
obtain a correct diagnosis of the deformity, it is necessary to
have the following:
• An extensive knowledge of the different mammary
remodeling techniques
• Good knowledge of the survival of the different glandular
correction flaps in relation to the vascular net on which
the corresponding pedicles are based
• Good observation skills to detect intraoperative defects
• Patience and perseverance to ensure success, with a single
surgical stage only when possible
E. Muti, MD
Dipartimento di Scienze Cliniche e Biologiche,
Università di Torino, Orbassano, Turin, Italy
e-mail: eglemu@tin.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_20
Furthermore, because we are almost always dealing with
young patients, we should carefully consider what is known
as the fourth dimension, namely the “time” factor, with all its
consequences and possible complications.
This type of malformation carries great psychological
impact and severe relationship implications because these
breast deformities sometimes present a grotesque appear-
ance and can seriously influence the fundamental perception
of patients’ femininity. This is the main reason why patients
affected by these malformations seek surgical help at a very
young age, sometimes as early as the beginning of adoles-
cence when, from a strictly surgical point of view, corrective
surgery should be considered inappropriate. However, in
these cases the possible psychological damage that could
negatively influence the psychological and emotional growth
of these young patients should be taken into consideration.
Therefore, the evaluation of the appropriateness of the surgi-
cal intervention should be conducted very carefully, analyz-
ing each single case on its merit, with the help of a
psychologist and the involvement of the patient’s parents.
Crucially, in my experience to date I have never seen an
improvement of tuberous breast deformity as the patient
ages; on the contrary, I have always noticed a worsening of
the condition.
It is always better to surgically correct this develop-
mental disorder and to intervene later with a possible
secondary revision, rather than to subject the patient to
prolonged psychological therapy while facing the
mental problems inflicted by such a deformity on the
patient’s psyche.
Considering these multiple aspects, when we face a
patient with this type of congenital malformation of the
breast, it is of fundamental importance to conduct a correct
and detailed initial interview beginning with preliminary
259
260
preoperative planning to obtain, as far as possible, an appro-
priate knowledge of the patient. This includes a general clini-
cal evaluation, a local morphological evaluation, and, last but
not least, an understanding of the patient’s expectations
obtained through “clarifying questions.”
2 Clinical Classification
2.1 General Clinical Evaluation
General clinical evaluation should include family history and
personal anamnesis, taking into consideration patient aller-
gies and possible food intolerances, and social habits, with
special attention to psychiatric and behavioral disorders such
as eating disorders. All clinical and social history has to be
considered to rule out any long-term effect on tissue struc-
ture and dystrophy.
A patient in less than perfect health is a good candidate
for postoperative complications.
2.2 Clinical Evaluation of Local Morphology
This assessment should take into consideration the shape of
the breasts, their nosological classification, possible asym-
metry, skin quality, osteomuscular morphology of the thorax,
and the possible presence of scars from past surgeries.
2.3 Psychological Evaluation
and Understanding the Patient’s Real
Expectations
This is a fundamental aspect of this type of surgery. A
depressed patient will very likely be an unsatisfied patient;
quite often the expectations in young patients are “very
high,” not having clearly in their mind the difficulties their
malformation presents. Therefore, the surgeon must main-
tain the proper balance between the duty to explain the dif-
ficulty of the case but without causing any anxiety or panic in
the patient. This may require several interviews leading to a
good and mutual understanding.
In the presence of a confused patient with a psychiatric
condition, it is advisable for the surgeon to decline or
postpone surgery.
E. Muti
2.4 Clarifying Questions
These questions will help the surgeon to better understand
patient’s expectations, for example: “how do you imagine
your scars will be?”, “what does a nice breast means to
you?”, “how big do you want them to be?”
3 Embryology
The breast develops from the ectoderm and penetrates
into the underlying mesenchyme, thus being incorporated
in the separation of the superficial abdominal layer called
the fascia of Scarpa; this consists of a superficial layer
that covers the mammary gland, and a deep layer that con-
nects the deep surface of the gland with the fascia of the
pectoral muscle and with the muscle of the anterior ser-
ratus [2].
Two thin layers of the superficial fascia are united
above the superior border of the breast into a single thin
layer, which then continues above the clavicle with the
superficial cervical fascial muscle aponeurotic system
(SMAS) [3].
The superficial and deep layers of the abdominal fascia
are connected by a system called the suspension ligaments,
represented by Cooper’s ligaments, which consist of fibrous
connecting tissue that seems to originate deep from the apo-
neurosis of the thoracic muscle and through the parenchyma
anchor itself anteriorly into the dermis.
4 Anatomical Pathology
Tuberous deformity seems to originate in an excessive rigid-
ity or hypertrophy of the periglandular capsule with a crani-
alization of the normal adherence between the superficial
layer and the deep layer of the fascia of Scarpa with the der-
mis, adherence that normally creates the inframammary fold
(IMF). Some authors describe it as a “fibrotic constricting
ring” at the periphery of the areola, more dense in the infe-
rior half of the breast.
In both cases, the expansion of the gland into the infe-
rior pole is prevented, and for this reason it projects itself
forward, concentrating behind the areola, thus projecting
the areola forward (see Tuberous Breast Type II: Fig. 3a
and c, right breast); in other cases the superficial layer of
the fascia of Scarpa is totally absent from behind the are-
ola and Cooper’s ligaments are lax or absent. The gland is
pushed forward, herniating into the areola, which becomes
enlarged and expands, sometimes completely, around the
small gland (see Tuberous Breast Type I: Fig. 1a, b and
2a, c).
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps
5 Tuberous Breast Classification
A clear and proper classification of tuberous breasts is a dif-
ficult and questionable task, but after several attempts I came
to distinguish three different types of tuberous deformity
with anatomical characteristics that can be assimilated and
corrected with similar glandular flaps. Following these
criteria the simplest clear and synthetic technique to face this
problem is, in my opinion, to describe each type of deformity
with its peculiar and most important morphological charac-
teristics, followed by its correction with its corresponding
type of glandular flap [4].
5.1 Type I
5.1.1 Fundamental and Most Common
Anatomical Characteristics
(a) The glandular tissue appears typically herniated, almost
completely, into the areola, which is expanded, some-
times in its inferior half, sometimes totally; there is
scarcity or absence of glandular cutaneous adhesion, so
the skin is relatively very lax.
(b) The IMF is very cranialized, sometimes up to the supe-
rior border of the areola, reducing drastically the infe-
rior mammary pole. Often one can appreciate a
“constricting fibrotic ring” which surrounds almost
completely the areolar skin, thereby comprising a great
portion or almost the entirety of the small mammary
gland.
(c) Frequently the small breasts are positioned very later-
ally on the thorax, externally to the hemiclavicular line
with a wide intermammary flat and empty space. (see
Cases 1, 2, and 5).
5.1.2 Type 1 – Glandular Correction
This is a central inferior glandular flap with an inferior pedi-
cle based on the superficial vascular net. The flap is created
with the portion of the gland that appears herniated into the
inferior portion of the areola, with its apex almost always
corresponding to the base of the nipple and the pedicle cor-
responding to the level of the fibrotic constricted ring, situ-
ated almost always to the inferior border of the areola or
pseudo-IMF. The size and shape of the flap will vary from
case to case, according to the quantity of gland herniating
into the areola.
The flap is incised at full thickness from the surface up to
the muscular thoracic plane. One then proceeds to under-
mine the residual gland from the deep plane and the soft tis-
sue of the thorax caudally to the gland, so as to create the
prosthetic pocket and lower the IMF to the desired level.
261
The flap is folded deeply and caudally with its apex
toward the new IMF with a movement similar to flexing a
finger (see Cases 1 and 2).
The surgical procedure continues with other details such
as lifting, reduction of the areola, remodeling of the retro-
areolar glandular tissue, which is then joined to the new infe-
rior pole. The procedure is completed by placing the
mammary prosthesis and performing cutaneous synthesis.
5.2 Type II
5.2.1 Most Common and Fundamental
Anatomical Characteristics
(a) Generally hypoplastic and dense gland
(b) Solid skin with strong cutaneous glandular adherence
(c) Small, sometimes very small, areola (non-expanded)
(d) Mammary base rather small and constricted, especially
in its inferior half
(e) The gland is solid, protruding behind the areola and
pushing it forward
(f) Inferior pole is absent, flat, or concave
(g) IMF is absent
(h) The small glands are, almost always, rather high on the
thorax (as in tubular breast type I), with a flat and wide
intermammary space.
(i) Quite often, after careful observation, a typical defor-
mity of the mammary profile can be appreciated, due to
a retro-areolar and infraglandular areolar protrusion,
which is still evident even after distension of the inferior
pole via releasing incisions according to Aston [1], and
placement of a prosthetic mammary implant.
This typical, seemingly insignificant, deformity is
enhanced by the white line contouring the profile of Fig. 3a–r
(Case 3). This will be corrected with a type II glandular flap.
5.2.2 Author’s Technique
To correct type II tubular breast, different types of flap cor-
rection can be used depending on the presence of some mor-
phological characteristics, such as:
• Quantity of glandular mass present
• Thickness of the tissue covering the thorax
• Major or minor evidence of the mammary profile deformity
Thus, we can distinguish:
1. Glandular flap type II
2. Glandular flap type III
3. Glandular flap type IV
262 E. Muti

5.2.3 Type II 5.3 Type III

I normally use this type of flap to correct the inferior retro-
areolar protrusion, typical of many type III tuberous breast
deformities (see Case 3, Fig. 3f). This flap is created through
a small inferior periareolar incision; by doing so I tackle the
“glandular protrusion” undermining it from the areolar skin,
just enough to sculpt the flap, leaving it pedicled to the glan-
dular surface.
The flap is then caudally folded, anteriorly below the
undermined skin of the inferior pole in its central portion.
By doing so I achieve simultaneously the removal of the
small retro-areolar protrusion, the relaxation and stretching
of the skin of the central portion of the inferior pole, and the
filling of the flat portion of the inferior pole, thus giving a
round appearance to the mammary profile (see Case 3,
Fig. 3g–o).
This small and relatively simple flap is capable of
producing surprising improvement in the mammary
profile and symmetrization with the contralateral
breast.
5.3.1 Most Common and Fundamental
Characteristics
(a) Moderately hypoplastic or normoplastic breast
(b) Tubular morphological appearance
(c) Dive-like ptosis and nipple–areola complex (NAC)
positioned downward and caudally
(d) Short distance between NAC and IMF
(e) Roundish mammary base, positioned fairly high but not
too lateralized on the thorax
Often this type of deformity is most common in asym-
metric cases in which the contralateral breast presents,
almost always, a type II deformity. In 90 % of the
cases, type II deformity is on the right breast.
See Case 3 (Fig. 3a–c) and Case 4 (Fig. 4a–c).

6 Clinical Cases with Different Types

5.2.4 Glandular Flap Correction Type III of Deformity, Preoperative Planning,
I use this type of flap in some certain types of tuberous defor- Intraoperative Sequence, and Results
mity, which fall under the category of type II but with a spe-
cific retro-areolar protrusion that involves the entire periphery Case 1. Bilateral and Symmetric Tuberous Breast Type I
of the areola. With such a flap the superior border of the in a 23-Year-Old Patient
areola is flattened, and by transposing such a flap inferiorly,
softening of the inferior protrusion with improvement in the
mammary profile is achieved. a
This flap is created by sculpting a roughly rectangular flap
into the deep glandular surface at the level of the half superior
portion of the areola, where the retro-areolar glandular pro-
trusion is located. The flap can have a lateral or medial pedi-
cle, which is transposed inferiorly and caudally to the inferior
border of the retro-areolar protrusion where deep glandular
incisions on the mammary base were previously performed.

5.2.5 Glandular Flap Correction Type IV

This flap is utilized to correct tuberous deformity type II
whereby the quantity of mammary mass is greater and the
mammary base is not so narrow. This is a deep glandular flap
that incises the deep surface of the gland at the level of the
half areola, and splits the mammary thickness into a flap
which is stretched toward the new IMF to create (or aug-
ment) the inferior pole with a movement simulating the Fig. 1 (a) In this projection the inferior halves of the areolas, slightly
expanded, containing a portion of the mammary gland herniating into
opening of a closed hand. This “unfurling” or expansion flap
them are clearly visible. Skin quality is excellent. Breasts are well posi-
[3] has been varyingly described by Gasperoni et al. [5] and tioned on the thorax and not too lateralized, with a wide, but still accept-
Persichetti et al. [6]. able, intermammary space
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 263

b c

Fig. 1 (b, c) In these oblique projections there is clear evidence of a distance between the inferior border of the areola and the IMF or
glandular prolapse into the inferior half of the areolas; the cranialization pseudo-IMF; and the inferior semicircular fibrotic constriction
of the IMF or pseudo-IMF; the absence of the inferior pole; the short

Graphic sequence of correction flap utilized to correct

Case 1 e

Fig. 1 (e) This drawing shows the periareolar de-epithelialization and

the beginning of the prolapsed gland incision, perpendicularly up to the
thoracic muscle plane, to create a glandular flap with its apex at the base
of the nipple and its base at the level of the inferior border of the areola
Fig. 1 (d) Preoperative skin drawings with markings of the rhombus- (Muti E. La Mammella Tuberosa. SEE Editrice, Firenze, 2010)
shaped periareolar portion to be de-epithelialized to reposition the are-
ola; and markings of cutaneous excisions from the inferior pole,
corresponding to the projection of the herniated gland (Muti E. La
Mammella Tuberosa. SEE Editrice, Firenze, 2010)
264
f h
Fig. 1 (f) The flap is completed and stretched externally (Muti E. La
Mammella Tuberosa. SEE Editrice, Firenze, 2010)
g
Fig. 1 (g) The flap is deeply and caudally folded with its apex toward
the new IMF (Muti E. La Mammella Tuberosa. SEE Editrice, Firenze,
2010)
E. Muti
Fig. 1 (h) This end-of-surgery drawing shows the flap positioned into
the inferior pole with its apex toward the new sulcus, and in transpar-
ency the prosthesis positioned in the prepectoral plane is observed
(Muti E. La Mammella Tuberosa. SEE Editrice, Firenze, 2010)
Intraoperative sequence of Case 1
Fig. 1 (i) Preoperative skin drawings performed with the patient in the
upright position. Careful evaluation is done through palpation of the
quantity of gland that will form the flap, and quantity of skin to be
excised to flatten the areolar enlargement and increase the conization of
the mammary apex
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 265

j l

Fig. 1 (j) After cutaneous excision, the glandular prolapse is evident Fig. 1 (l) The flap, undermined up to the thoracic wall, is stretched
outwardly. It will be then folded internally bringing the apex up to the
new IMF. At this stage, through the existing cutaneous incisions, the
prosthetic pocket is prepared and the prosthesis is implanted, the retro-
k areolar glandular plane is sutured, and the cutaneous plane is closed,
which will result in a periareolar scar devoid of any tension and a short
vertical scar

Result of Case 1

Fig. 1 (k) By incising the prolapsed gland at its medial and lateral bor-
ders, at full thickness up to the thoracic wall, a flap is created that in this
picture is shown to be placed back in its initial position

Fig. 1 (m) Result 15 days postoperatively

266 E. Muti

n o

Fig. 1 (o) Result 1 year postoperatively

Fig. 1 (n) Result 15 days postoperatively

p q

Fig. 1 (p, q) These lateral projections, taken 1 year postoperatively, show evidence of good breast conization, good symmetry, and total correction
of the deformity
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 267

r s

Fig. 1 (r, s) These oblique projections 5 years postoperatively show good and long-lasting result of the correction, and the breasts appear soft and
natural

t u

Fig. 1 (t, u) Five years postoperatively there is further evidence of soft and mobile breasts and undetectable scars
268 E. Muti

Case 2. A Second More Severe Example of Tuberous

c
Breast Type I
Severe tuberous deformity in a 17-year-old patient, which
presents all the morphological anomalies described in Case 1
but in a more extreme manner.

Fig. 2 (a) In this frontal projection we can appreciate the large areolar
expansion and the position of the very cranialized mammary base rather
high on the thorax, with a wide, completely flat, intermammary space
Fig. 2 (c) The extremely lax areolar skin does not have any adherence
to the gland that contains it. This could demonstrate the absence of the
superficial layer of the fascia of Scarpa and the absence of Cooper’s
ligament at the level of the areola. The outer skin of the areola is lax and
presents numerous striae. In this projection, also evident are the fibrotic
ring that completely surrounds the small mammary footprint on the tho-
rax and its extreme lateralization with a very wide, totally flat inter-
mammary space
Intraoperative sequence of Case 2

The extensive areolar expansion increases the diffi- d

culty of this case because the preoperative markings
are forced to follow its periphery, leading to a larger
than intended cutaneous excision.

Fig. 2 (d) Preoperative cutaneous markings are drawn with the patient
on the operating table. There is a discrepancy between the two cutane-
ous incisions

Fig. 2 (b) In these oblique projections we can better appreciate the

small glands totally prolapsed into a cutaneous areolar sack with an
IMF extremely cranialized near the superior border of the gland; they
therefore appear as small sacs hanging onto the thorax by a narrow base
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 269

e g

Fig. 2 (e) After the periareolar de-epithelialization and repositioning

of the areola, the prolapse of the small gland on the thorax is evident

Fig. 2 (g) The glandular flap is folded over itself, inferiorly under the
f skin, with its apex brought deeply and caudally toward the new
IMF. The vascular pedicle of the flap is based on the dermal vascular net

Fig. 2 (f) The thin layer of dermis that covered the gland has been
undermined up to the inferior border of the areola; here it is cranially
stretched to be then utilized to thicken the areola and be positioned
between the ducts. The mammary gland devoid of the dermis is incised
at the level of the areola inferior border, perpendicularly up to the tho- Fig. 2 (h) In this case the free margin of the flap is spread like a fan,
racic plane, and is then enlarged by incising centrally and vertically to through several small vertical incisions, to thicken the skin of the newly
create a rather wide, roughly square flap created inferior pole, thence to be fixed into the desired position with
transcutaneous stitches
270 E. Muti

Graphic sequence of the surgical procedure utilized for

k
Case 2

Fig. 2 (k) The flap is deeply and caudally folded. (Muti E. La

Mammella Tuberosa. SEE Editrice, Firenze, 2010)

Fig. 2 (i) The thin layer of the inferior pole is undermined up to the l
inferior border of the new areola, exposing the gland, which is incised
at full thickness starting from the areola inferior border to reach the
thoracic-muscular level, maintaining the inferior cutaneous pedicle.
(Muti E. La Mammella Tuberosa. SEE Editrice, Firenze, 2010)

Fig. 2 (l) In this drawing we can appreciate the flap deeply folded over
itself so as to create an inferior pole, and then extended with its free
margin fixed along the new IMF. (Muti E. La Mammella Tuberosa. SEE
Editrice, Firenze, 2010)
Fig. 2 (j) A quadrangular flap is created that in this drawing is shown
stretched out; on its inferior border numerous small incisions are per-
formed to give it a fan-like shape, thus allowing its distribution in the
inferior border along the new IMF. (Muti E. La Mammella Tuberosa.
SEE Editrice, Firenze, 2010)
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps
Result of Case 2
Fig. 2 (m) Results 10 years postoperatively. There is a satisfactory
shape of the breast, good filling of the intermammary space, and good
symmetrization. Scarring is also satisfactory, although a few inferior
periareolar striae still remain
n Left Side General considerations. This type of malforma-
Fig. 2 (n) Results 10 years postoperatively. This oblique projection
shows a satisfactory breast shape with an adequate volume and ade-
quate areolar projection into the inferior pole
271
o
Fig. 2 (o) Long-term results at 18 years postoperatively
Case 3. Asymmetric Tuberous Breast with Tuberous
Deformity Type II on the Right Side and Type III on the
tion represents a double challenge because it sums up the
difficulty of the tuberous deformity with the added difficulty
of the breast asymmetry.
As we are dealing with young patients, we must aim for
good results that will be stable and long-lasting. Therefore,
we take into consideration the factor defined in Plastic
Surgery as the “fourth dimension,” namely, the passage of
time, with its effect on body morphology and changes such
as pregnancies and mere aging.
It is fairly evident that a prosthetic breast will not undergo
the same modifications as the natural breast; my motto,
therefore, in cases of mammary asymmetry where one breast
requires a mammary implant, is: “To reduce the bigger breast
to the size of the smaller one, in order to use two equal pros-
theses when this option is possible.”
It is obvious that such a choice has certain “limits”
because we must consider the volume of the bigger breast.
According to this concept, it is very important to obtain at
least two similar situations on both breasts, not only in regard
to dimensions but also the shape.
To achieve this result, I suggest performing a procedure
called Aimed Subcutaneous Segmentary Glandular Resection
(ASSGR). This procedure requires a very careful preopera-
tive observation and palpation of the breasts with the patient
in a standing position to discern the appropriate site and the
correct quantity of gland that needs to be excised, thus reduc-
ing the bigger breast to the shape and volume of the smaller
one. When this approach is not possible, we must attempt to
symmetrize both breasts with two different prostheses.
272
a c
Fig. 3 (a) The asymmetry of volume and shape, and the extreme later-
alization of the areolar complex are shown
As already stated in the general description of the dif-
ferent types of tuberous breast, type III deformity
appears more often on the left side, such as in this case,
associated with a type II deformity on the right side.
b
Fig. 3 (b) This projection shows the tubular deformity of the left breast
with a slight dive-like ptosis
E. Muti
Fig. 3 (c) This projection shows the right breast type II tuberous defor-
mity and its constricted inferior pole
Preoperative planning of Case 3
d
Fig. 3 (d) On the right side are marked the new IMF position and the
access to the prosthetic pocket through the IMF. In this case the position
of the prosthesis will be pre-pectoral. On the left breast a yellow line has
been drawn to mark the site of the Aimed Subcutaneous Glandular
Resection intended to reduce the breast. Also marked is the small peri-
areolar cutaneous rhombus to guide symmetrization of the areolas
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 273

Intraoperative sequence and graphic correction of type

e
II deformity of the right breast utilizing flap correction
Glandular type II
resection

g
Residual
gland

Glandular
flap

Fig. 3 (e) This figure shows the area of glandular resection of the left
breast and a small flap rotated under the skin to better fill the inferior
pole

f Fig. 3 (g) The prosthesis has been introduced in a retro-pectoral plane

where previous radial releasing incisions of the constricted pole were
performed; the incision from the IMF has been closed. However, the
inferior pole still appears slightly flat and tense while in the areola infe-
rior half we can observe a glandular, though small protrusion, which
can be released through a small inferior periareolar cutaneous incision

Resezione
ghiandolare
sottocutanea

Fig. 3 (f) In this projection the white line shows and enhances the typi-
cal subareolar tuberous deformity of the right breast, the absence of the
IMF. and the tension of the concave inferior pole
Fig. 3 (h) This drawing shows more clearly what has been described in
Fig. 3e: the persistence of a certain degree of the mammary profile
deformity, despite releasing incisions on the inferior pole, and the use
of an anatomical implant
274 E. Muti

i l

Fig. 3 (i) Through the small inferior periareolar incision, a certain Fig. 3 (l) The flap is superficially rotated below the undermined skin
amount of protruding gland is evident and the areolar skin is under- from the center of the inferior pole
mined almost to the base of the nipple; here the gland is incised, and by
utilizing this surplus we create a small glandular flap pedicled on the
anterior glandular surface of the inferior pole. On the skin of the infe-
m
rior pole is marked the subcutaneous site that will involve the small flap

Fig. 3 (m) This drawing corresponds to the surgical scenario of the

Fig. 3l (Muti E. La Mammella Tuberosa. SEE Editrice, Firenze, 2010)

Fig. 3 (j) The small glandular flap is created and stretched outward in
order to show it

Fig. 3 (n) The flap is positioned into the desired site and fixed, in this
case, with a transcutaneous suture. It is noticeable how the profile of
Fig. 3 (k) This drawing corresponds to the intraoperative scenario of inferior pole has completely changed
Fig. 3j (Muti E. La Mammella Tuberosa. SEE Editrice, Firenze, 2010)
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 275

o p

Fig. 3 (o) The position of the superficial small flap and the modifica-
tion of the mammary profile. (Muti E. La Mammella Tuberosa. SEE
Editrice, Firenze, 2010)

Fig. 3 (p) Result 4 years postoperatively. There is good symmetriza-

tion, and the excessive lateralization of the breasts is sufficiently dis-
guised by the filling of the mammary space

q r

Fig. 3 (q, r) These two figures show the good mammary shape, with the right inferior pole full and symmetric with the contralateral left breast.
The superior pole is soft and natural, with good projection of the NAC
276 E. Muti

b
The correction effect of a type II flap, although small
in size, is in my opinion mostly due to the undermining
of the skin of the inferior pole with interruption of the
fibrotic fascia, the cutaneous relaxation, and the inter-
position of the flap between the skin and the gland.

Case 4. Asymmetric Tuberous Breast with Tuberous

Deformity Type II on Right Side and Type III on Left
Side An 18-year-old patient with mammary shape and vol-
ume asymmetry, and tubular breast type III on the left side
and tuberous breast type II on the right side.
The right breast is severely hypoplastic while the left
breast can be considered slightly or moderately hypoplastic.
Volume asymmetry is such to allow, in my opinion, the
application of my basic concept of adjusting the bigger Fig. 4 (b) This picture shows the left breast, with cranialized IMF and
breast to match the volume of the smaller one, symmetrizing dive-like ptosis
the shape in order to utilize two equal prostheses.

c
a

Fig. 4 (a) Shape and volume asymmetry is evident, with the presence
(as often occurs) of hypoplastic tuberous deformity on the right side.
The panniculus adiposus is well represented and skin is of good quality, Fig. 4 (c) This oblique projection shows the right breast, with its infe-
with the presence of few cutaneous striae rior pole constricted and concave and absence of the IFM

The lateralization of the areolas is evident, especially on

the right side. Slight retro-glandular protrusion, absence of
the right IMF, and areolar enlargement of the left breast are
also evident.
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 277

d e

Fig. 4 (d, e) With the patient in a standing position, skin markings are
drawn, including the medial-sternal line and the jugular-nipple line, which
shows 4 cm difference between the right and left nipple. Also marked is
the position of the left IMF and the new right IMF, which is positioned
approximately 1 cm more caudally than the left IMF. These lines are
drawn with the patient keeping her arms at her side so that a light abdomi-
nal lifting of the skin, a greater softness, and redundancy of the skin infe-
rior pole can be obtained later. The “XXX” drawn on the right breast
corresponds to the point of maximum concavity and tension of the inferior
pole, which will correspond to the point of its maximum protuberance

On the left breast are marked the lines for mastopexy

using the vertical technique with reduction of the areola, and f
markings for the periareolar de-epithelialization of the infe-
rior pole.
Graphic sequence of surgical technique
For the right breast: glandular flap type IV or unfurling
flap, or expansion of the mammary base.
This flap allows us to achieve two goals: the opening and
relaxation of the mammary base, and the thickening of the g
inferior pole.
This technique, with few variations, has been described
by Benelli [7, 8], Botti [3] (who calls it “mammary expan-
sion”), and Persichetti et al. [6].
In some cases two flaps cans also be utilized, one laterally
and one medially to the areola, leaving untouched the area
under the subareolar region in order to maintain its
projection.
h

Fig. 4 (f–h) Schematic lateral vision of the deep glandular flap (f), describ-
ing a transverse incision of the surface of the deep gland, corresponding to
the retro-areolar region; we then proceed caudally to help thicken the gland
to create a flap (a), which is brought caudally under the skin of the new
inferior pole, stretching the mammary base up to the new IMF (g, h), with
a movement similar to the downward opening of a clenched fist (Muti E. La
Mammella Tuberosa. SEE Editrice, Firenze, 2010)
278 E. Muti

Result Case 5. Tuberous Breast Variant of Type I: A Peculiar

Case We may consider this as a variant of type I. Although
i less hypoplastic, it presents some common characteristics,
such as: a very cranialized IMF, with a nearly totally con-
stricted mammary base; an extreme lateralization of the
breast on the thorax; a nearly totally prolapsed gland into an
extremely expanded areola; a reduced cutaneous glandular
adherence; and a wide intermammary empty space. The tho-
racic and abdominal adipose tissue is well represented.

Fig. 4 (i) Result 6 months postoperatively. Scars are still healing and
are therefore still noticeable. There is good symmetrization of shape
and volume, and position of the IMF

Fig. 4 (j) Result 6 months postoperatively

Fig. 5 (a, b) These two pictures show the cutaneous markings for the
reduction of the cutaneous sac. Clearly evident is extreme breast lateral-
ization with a pedicle that starts laterally from the anterior pillar of the
axilla. This characteristic, together with the cutaneous areolar expansion,
which has lost its contour in its inferior half of the de-epithelialization
area in the inferior pole, represents the particular difficulty of this case

Fig. 4 (k) Result 6 months postoperatively

Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 279

The surgical correction of this case aims to achieve the

d
fullness of the central thoracic regions without positioning
the prosthesis too medially, because this could further later-
alize the areolas. This can be attained through mobilizing
and transferring the glandular flaps from the lateral region to
fill the medial region and then positioning the mammary
implants at the center of the mammary cone. The flap in this
peculiar case, unlike other flaps so far described, is created
with a lateral pedicle, which allows the dragging of the
greater part of the gland toward the medial quadrants.

This flap can be considered as a variant of a type IV

flap; in fact it applies the same concept of “opening the
mammary base” and its “relaxation,” but in this case in
a lateral-medial sense rather than a craniocaudal sense.
Intraoperative sequence
Fig. 5 (d) The dermal flap is lifted and, on the glandular surface, the
dotted lines are marked to define the glandular incisions, which will
allow the creation of the glandular flaps that will be mobilized above the
mammary prosthesis: the small central flap (1) with a superior pedicle,
a lateral flap (2) with a lateral pedicle, and a medial flap (3) with a
medial pedicle

c e

Fig. 5 (c) In this intraoperative illustration we can appreciate the
reduced and cranially repositioned areolas with one stitch at the
12-o’clock position. The de-epithelialization is performed according to
preoperative skin markings. The dermis of the inferior pole is under-
mined from the glandular surface up to the inferior border of the
reduced areola
Fig. 5 (e) The three flaps are prepared: the small central flap (1) with a
superior pedicle; the lateral flap (2) resulting from the “unfurling” and
relaxation of the gland that will constitute the lateral inferior quadrant
(Q3) and portion of Q4; and the medial flap (3), formed by the “open-
ing” of the gland of the medial inferior quadrant. The pre-pectoral pros-
thetic pocket is then prepared
280
f h
Fig. 5 (f) The central flap (1) has been cranially folded over, below the
areola, to give it projection. The lateral flap (2) is, as much as possible,
pulled medially to form part of the inferior pole, which will cover the
prosthesis. The flap (3) is positioned above the flap (2) toward the
medial line. Once the flaps are fixed in their positions, the prosthesis is
introduced. The dermal flap is repositioned on the gland at the center of
the inferior pole, after which the skin incisions are sutured
Graphic sequence of surgical procedure for Case 5
Fig. 5 (g) The three flaps are sculpted and the dermal flap is lifted.
lateral flap (lf), central flap (cf), medial flap (mf) (Muti E. La Mammella
Tuberosa. SEE Editrice, Firenze, 2010)
E. Muti
Fig. 5 (h) The small central flap (cf) is cranially folded over under the
areola. The lateral flap (lf) is brought medially and its medial border
fixed on the thoracic surface and, as much as possible, medially under
the medial flap (mf) (Muti E. La Mammella Tuberosa. SEE Editrice,
Firenze, 2010)
i
Fig. 5 (i) In transparency we can see that the central flap (cf) is brought
cranially; the lateral flap (lf) is brought medially; the medial flap (mf) is
brought centrally-laterally; and the dermal flap is repositioned on the
gland below the skin centrally to the inferior pole (Muti E. La Mammella
Tuberosa. SEE Editrice, Firenze, 2010)
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps 281

Result
l

Fig. 5 (j) Result 2 years postoperatively. Shape appears natural. The Fig. 5 (l) Result 2 years postoperatively. The areolas are still some-
areolas are still laterally positioned, but the medial quadrants are fuller what large, due to the redistribution of most of the peripheral periareo-
and appear more normal, and the defect is disguised lar skin in order to reduce the vertical scar and perform a small
refinement at the submammary sulcus

Fig. 5 (k) Result 2 years postoperatively. Satisfactory form and vol-

ume of the breasts that appear to be proportionate to the patient’s body
habitus
282
m
n
Fig. 5 (m, n) Result 2 years postoperatively. We can appreciate the
good shape of the mammary cone with proper projection under the
areola; sufficient dimension has been obtained, thus satisfying the
desire of the patient
7 Surgical Failures and Complications
This type of malformation is considered a true surgical chal-
lenge by many plastic surgeons because it is considered a
reconstructive rather than aesthetic surgery; therefore, a cer-
tain percentage of failures and/or complications that will
E. Muti
sometimes need surgical revision should be taken into
account. Fortunately, I have encountered few cases of such
failures and complications, probably because of my almost
manic attention and precision to the smallest detail, notwith-
standing the time I spend in the operating room. This last
aspect has been often criticized by many because it is very
costly; however, this apparent expense id offset by achieving
a satisfying solution with only one surgical procedure, thus
reducing the risks of probable and possible future costly
revisions.
8 Case List of Postoperative Failure
and Complications
In more than 30 long-term follow-up cases performed with a
single-stage surgical procedure, I encountered the
following:
8.1 Failures
• Perfect results: with residual, although very mild, defor-
mity: 4 cases.
• Residual slight asymmetry, in those cases with asymme-
try: 2 cases.
• Bad scars that required second revision: No cases.
8.2 Postoperative Complications
• Partial de-epithelialization of the areola with spontaneous
resolution that did not require secondary revision: 1 case.
• Rotation of the anatomical prosthesis inserted in retro-
pectoral pocket, with partial dislocation of the prosthesis
under the IMF, waiting for secondary revision: 1 case.
• Severe capsular contraction (grade IV Baker) with cuta-
neous erosion and prosthetic visibility at the center of the
inferior pole. This severe complication occurred in a
patient presenting with type II tuberous breast deformity
corrected with relaxation of the tense inferior pole through
radial releasing incisions, a prosthetic implant inserted in
a pre-pectoral pocket, and a small type II flap to give
roundness to the inferior pole.
Since the patient lived in a different town (a fact that some-
times compromises the possibility of postoperative follow-ups)
and because patients do not always comprehend or cannot
understand the significance of certain symptoms or clinical
information and do not promptly report those problems to the
surgeon, the initial complication which could be promptly
treated may become a severe complication that compromises
the final result.
Tuberous Breast: Different Morphological Types and Corresponding Correction Flaps
In this particular case, which presented a good postopera-
tive result, the complication occurred 1 month after the last
postoperative follow-up. The patient underestimated a pro-
gressive capsular contracture and failed to report this to her
parents and doctor until a fistula occurred with consequent
cutaneous erosion and prosthetic exposure.
The patient underwent explantation of the left prosthesis,
total circumferential capsulotomy and partial peripheral cap-
sulectomy in the inferior quadrants, enlargement of the pros-
thetic pocket, lipofilling to obtain softness in the fibrotic
capsule, and folding of a glandular capsular flap from the
subareolar region to cover the deep cutaneous breach, which
was then repaired at its borders and sutured with intradermal
and superficial stitches.
A small mammary expander was introduced.
The recurrence of a cutaneous fistula, a month later, at the
same site required the explantation of the expander (surgery
was performed in a different town by a different surgeon).
This was my first serious complication my professional
career which was due, in my opinion, to improper behavior
by a patient during her postoperative period. This has
taught me how important it is for the surgeon to conduct a
thorough psychological examination of the patient to antic-
ipate possible postoperative behaviors. We must also
emphasize from the beginning the consequences and risks
that certain behaviors will have on the outcome, without
scaring the patient off.
Never overestimate a patient’s ability to understand
that which is obvious to the surgeon.
No plastic surgeon is ever safe from such frustrating
experience.
Infections: If we exclude the possibility that I encountered
such a complication in the case described above: No cases.
9 Final Considerations
In this chapter I have attempted to concisely share my expe-
riences in the treatment of tuberous deformity of the breast,
including all the difficulties I tried to overcome along the
way.
Today, however, there is a new approach already under
way, called lipostructure, which when applied in selected
cases can achieve good results; in other cases it can easily
correct less than perfect or mediocre results.
283
In selected cases it may even solve the malformation
problem without the use of a mammary prosthesis. This new
technique is a potential optimal solution and undoubtedly
offers advantages for younger patients with respect to avoid-
ance of problems and inconveniences arising from prosthesis
implantation and the aging factor.
The disadvantages and limitations of this technique
mostly concern the following:
• The necessity of repeated surgical operations whose num-
bers are not foreseeable although they are performed
under local anesthesia and in an outpatient setting
• The presence of fat tissue, not always available when
needed
• Difficulty or impossibility of correcting some types of
deformity (see Case 2) without the utilization of other sur-
gical techniques such as glandular flaps, previously
described
• Difficulty in remodeling the mammary shape
Therefore I believe, together with my fellow surgeons, that
this interesting and useful technique cannot and should not sub-
stitute completely the different techniques thus far employed to
correct tuberous deformity [10–25], but it could certainly help,
and make the final result easier to achieve and safer, with or,
even better whenever possible, without a prosthesis.
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 Gynecomastia
Carlo Cavina
The word “gynecomastia” literally means female breast.
With the same word we commonly refer to an evident
increase in volume of the male breast, which thus resembles
a feminine breast [1]. Gynecomastia, already known in
ancient times, thus represents by far the most common
benign condition of the male breast. The term is purely
descriptive and refers only to a state of altered external
morphology in excess, regardless of the type of tissue
hyperplasia. It is not correct, therefore, to divide gynecomas-
tias into true or false only in relation to a fatty or glandular
component as the cause of the increased volume. It seems
more correct to speak about gynecomastia in a broad sense
(increase in volume of the male breast), specifying and defin-
ing the type: glandular, adipose, or mixed. Gynecomastia can
be a symptom of diseases resulting in a general endocrine
imbalance, and therefore they can sometimes be cured sim-
ply by an appropriate medical therapy [2]. Other times it can
be neglected as an expression of minor importance in rela-
tion to the complexity and severity of an underlying disease
(e.g., kidney cancer, liver cirrhosis). Often, on the basis of
unknown etiology, it represents itself as a pathological con-
dition, not linked to other diseases; it can thus be defined as
idiopathic gynecomastia. It severely affects social life and
equally can cause serious psychological disturbance [3].
These most frequent forms, occurring in teenagers and even
in young adults, have a surgical indication, as successful
results can normalize an altered morphology and beneficially
affect intimacy and affection. Perhaps more than any aes-
thetic surgery in men, the correction of gynecomastia can
C. Cavina, MD
Dipartimento di Scienze Chirurgiche Specialistiche,
Anesthesiologiche, Università di Bologna, Bologna, Italy
e-mail: carlo.cavina@unibo.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_21
positively affect the emotional aspect of the young patient,
avoiding future worsening of self-esteem. Much has been
written about the etiology of gynecomastia and its correla-
tion with underlying endocrine disorders. This has been
described in detail in several chapters of internal medicine
and pediatric textbooks, but has little surgical interest.
However, it remains undisputed that the vast majority of
cases that come under our observation do not have a recog-
nizable cause. Typical patients are teenagers and young
adults in whom the temporarily modest increase in volume
of the breast (normal at their age) does not cease, gets worse,
and in the end stabilizes over time. Patients are often initially
referred to their pediatrician or family doctor and have
already been fully investigated (clinically and with labora-
tory tests) in the search for some cause of hormonal imbal-
ance. They are subsequently referred to us because surgery is
the only feasible remedy. Sometimes, although the possibil-
ity is rarer, a patient suffering from gynecomastia is directly
referred to us, requesting surgical correction. In these cases
we order laboratory tests and an endocrine consultation to
rule out other causes before evaluating surgery. Finally, there
are neglected cases whereby correction may be required in
patients with true diseases (e.g., patients on renal dialysis,
cirrhotic patients, or patients on anabolic steroids). A sepa-
rate consideration must be made for the rare forms of gyne-
comastia in which the increase in breast volume occurs in
children suffering from neurofibromatosis type 4 (Fig. 1a, e).
In this instance gynecomastia occurs early, in the prepubertal
age range. The external appearance of the breast is compa-
rable to that seen in idiopathic postpubertal gynecomastias,
and the consistency is similar to those with a major glandular
component. Here even prepubertal surgery may be indicated,
with resection of pathological neurofibromatous tissue, using
the same techniques as for forms of idiopathic gynecomastia
(Fig. 2b, c).
285
286 C. Cavina

a b

d e

Fig. 1 Gynecomastia in a 9-year-old boy with neurofibromatosis. The 5 years after surgery using a periareolar approach. (c) Pathology of
severe clinical aspect is caused by neurofibromatous tissue located (for resected tissue. (d) Same patient before surgery and (e) after 5 years
unknown reasons) electively in this area. (a) Before surgery and (b) after surgery
Gynecomastia
Fig. 2 (a) Pure glandular gynecomastia in 16 year old male. (b) The ability to expose the mammary gland and resect the excess. (c) 2 years
postoperative
1 Classification and Clinical Aspects
A first major classification is made with regard to
etiopathogenesis. The first distinction, therefore, is made
between idiopathic forms (i.e., for which we do not recog-
nize a cause) and all other forms in which gynecomastia is a
symptom of a systemic disease.
287
For practical reasons and in relation to the various
methods of surgical treatment, a distinction based on
pathology is always desirable. Three kinds of gynecomastia
can be recognized:
1. Gynecomastia primarily due to hypertrophy of the
mammary gland (Fig. 3a)
288
a
b or without extra-areolar incisions. In the vast majority of
c symptoms.
Fig. 3 The three forms of gynecomastia. (a) Glandular. (b) Adipose.
(c) Mixed
2. Gynecomastia mainly due to an excess of fatty tissue
(also known, but inappropriately, as false gynecomastia)
(Fig. 3b)
3. Mixed gynecomastia, in which the increase in volume of
the breast is due to both the glandular hypertrophy and
fat excess (Fig. 3c)
The forms belonging to types 2 and 3 are very often part
of a chest whose contours and reliefs of the muscles are
C. Cavina
softened and blurred in an abundant adipose tissue.
A classification of gynecomastia based on volumes (“small,”
“medium,” and “large”) is of limited usefulness and difficult
to achieve. The distinction of forms based on the breast vol-
ume may therefore have only a descriptive value [26]. It can
be sometimes useful, however, such as in the forms of severe
gynecomastias, whereby the type of reductive surgery is cho-
sen on the basis of volume and skin to be removed. This will
separate the forms for which a periareolar incision is enough
from the forms for which a skin excision with longer scars
(inframammary fold or inverted T) is needed. It is true, how-
ever, that even this distinction is often subjective, and ame-
nable to a personal assessment of the individual case and the
possibility of solving it, based on skills and experience, with
cases, even severe, there is no need for skin resections:
extended liposuctions, inframammary fold disruption, and
long-lasting compressive dressings allow adaptation and of
the skin envelope, with harmonic distribution over the tho-
rax. Typically, patients are young adults with comprehensive
skin elasticity and retraction.
2 Symptoms, Diagnosis,
and Additional Tests
Gynecomastia does not usually cause important pathological
Pain (mastalgia) and tension in the affected area are
described and reported only rarely. The disorders are instead
psychological; they are already present in teenagers and
become increasingly evident in patients who have lived
many years with a physical deformity that imparts such an
influence on social and private life. Usually in these patients
it is possible to observe a true psychosis, sometimes mild,
sometimes severe; rarely the psychosis is irreversible.
Diagnosis is based on clinical status. Inspection and palpa-
tion allow a classification of the various forms as already
discussed. Possible asymmetries should also be evaluated.
Possible irregularities in the hyperplastic parenchyma
should be checked for and, in doubtful cases, ultrasound and
mammography are useful investigations to rule out malig-
nancies. Histological examination of the resected gland is
mandatory. Moreover, tone and elasticity of the skin must
be evaluated; the better they are, the more the skin envelope
will be able to retract and redistribute over the chest. For
this reason, young age is a favorable factor. Hair distribution
and abundance should also be evaluated: this can influence
the surgeon particularly for external incisions, because a
hairy chest can easily hide scars. Moreover, the size of the
areola is important: a large areola allows for extensive tissue
excision, in particular for the glandular type of
gynecomastia.
Gynecomastia
Fig. 4 Intraoperative. (a) Liposuction is usually performed through both an areolar and inferior external quadrant incisions. (b) Subsequent resec-
tion is done through an inferior areolar incision
3 Histological Features
Histological features are fully illustrated. It is important to bear
in mind that stromal alterations are typical: there is a thickened
fibrous tissue where ductal structures are present. The periduc-
tal connective tissue resembles the typical “mantle-like” stroma
of the female breast. The ducts are often dilated and elongated.
3.1 Surgery
The purpose of the intervention is, of course, to reduce the
excessive volume of the breasts, thus to achieve an appear-
ance appropriate to the patient’s age and sex.
In this section we consider only surgery for teenagers and
young adults with mild to moderate gynecomastias. In these
patients it is possible to avoid external scars (such as inverted
or inframammary scars). In cases of severe gynecomastias
with large feminine breasts, techniques adopted are the same
as described for reduction mammaplasty and mastopexy, and
are outside the scope of this chapter. In purely adipose
gynecomastias, liposuction is the gold-standard technique.
289
In purely glandular gynecomastia, resection of the excess
glandular mass is performed through a periareolar incision.
In the mixed forms, liposuction and glandular resection are
appropriate, with the former being the first option.
This sequence appears to make sense because, after lipo-
remodeling, the remaining glandular component will be
more evident, and can be resected and reduced easily
(Fig. 4a, b) [7–24].
The patient is marked in the upright position with empha-
sis on the inframammary fold and the margins of the breast. In
mixed forms, within these margins (which correspond to the
softer fatty component), the glandular component is marked.
Liposuction is usually confined to the external boundaries,
whereas glandular excision is limited to internal boundaries.
General anesthesia is usually preferred. It is always asso-
ciated with extensive infiltration (up to 100 mL or more per
side) with a solution of adrenaline 1:400,000 and carbocaine
0.25 %. We prefer the classical hemi-periareolar incision
proposed by Webster [24]. The incision line (usually the
lower half of the areolar contour) is just inside the edge of the
pigmented skin. Other small incisions (the inframammary
fold, the anterior pillar of the axilla) can be added for
290
Fig. 5 (a) Paziente di 25 anni affetto da severa ginecomastia preva-
lentemente adiposa. (b) Controllo post-operatorio a 10 gg.
dall’intervento di lipoaspirazione. La estesa soffusione ecchimotica tut-
tora presente è segno dell’ altrettanto estesa area interessata dalla
lipoaspirazione. La lipoaspirazione su una grande estensione è stata in
a b
Fig. 6 (a) Schema di resezione della ghiandola nelle forme di gineco-
mastia esclusivamente ghiandolare. È necessario conservare un cusci-
netto di tessuto ghiandolare al di sotto dell’areola. La quantità di tessuto
adiposo del piano sottocutaneo rimane invariata. (b) Schema del tratta-
C. Cavina
grado di far scomparire l’evidente solco sottomammario e ha permesso
alla componente tegumentaria di ridistribuirsi sul volume ridotto della
mammella. Il diametro dell’areola si è spontaneamente ridotto e tale si
manterrà nel tempo
mento nelle forme di ginecomastia di tipo misto (di gran lunga le più
frequenti). La resezione ghiandolare viene effettuata dopo il tempo
della lipoaspirazione. Nella figura sono rappresentati, nel contesto del
tessuto adiposo, i “vuoti” creati dalla cannula da lipoaspirazione
Gynecomastia
liposuction. As already pointed out, the external incisions are
reserved only for severe cases. Liposuction performed in the
breast for gynecomastia does not differ in any way from
those performed in other areas.
Here we will not detail extensively a very common and
well-known technique, although several important points
are worthy of mention. Liposuction is able to achieve a
regular aspect of the operated thorax, preserving the
smoothness in boundaries. Sometimes the outer limits of
liposuctioned areas are very wide: they reach the sternum,
clavicle, midaxillary line, and abdomen, allowing suction
to a very large extent and a convenient redistribution of the
skin envelope. This allows correction of important and even
severe forms, without any problems of excess skin (and
consequently avoiding skin resection; Fig. 5). Liposuction
Fig. 7 (a) There is a high degree of mixed gynecomastia in males
under age 18. (b) One year postoperative – correction made is insuffi-
291
is extended well under the inframammary fold, completely
disrupting it. Glandular resection consists in removal of
disk-shaped tissue (Fig. 6a, b). Care must be taken in leav-
ing enough thickness under the areola to create the typical
aspect of the male breast. An excessive resection will deter-
mine an unnatural depression that can be limited to the
areola or, in severe cases, involve the whole breast because
of skin retraction. When large areolas are present, it is pos-
sible to observe a reduced diameter as early as the end of
surgery. This is caused by skin retraction, and is the reason
why surgical reduction of the areola diameter is confined
only to particular cases and is routinely not performed. The
resected gland is always sent to Pathology. Drains are left in
situ for 24–48 h. A compressive garment is worn for 10 days
at least, until suture removal, and then worn for 2 months.
cient. (c) Two years postoperative – satisfactory final result with normal
male chest configuration
292 C. Cavina

4 Single-Stage Versus Two-Stage technique [1, 2, 10, 12, 16, 25]. It must be specified that
Surgery results for gynecomastia surgery were scarce for a long
time, until the introduction of liposuction and its use
In some cases two-stage surgery should be considered, for together with surgical resection. This technique is now
several reasons. It is possible, for instance, for the residual
gland to become hypertrophic again should the underlying a
stimulus be still present. Other times, revision is second-
ary to insufficient tissue removal (Fig. 7). Sometimes,
however, a two-stage procedure can be planned from the
beginning, for example, in very severe forms of gyneco-
mastia with massive and ptotic breasts. Glandular resec-
tion and liposuction are practiced only partially in the first b
step, and then again in the second. This two-stage tech-
nique allows for better skin retraction over time (Figs. 8
and 9).

5 Discussion

Gynecomastia is a constituent of male breast diseases,

and is now well defined in its various endocrine aspects. c
A rich and comprehensive bibliography is available for a
thorough understanding of its various aspects (etiopatho-
genic, clinical, and pathological). In the surgical commu-
nity, liposuction is now a well-recognized and established

a Fig. 9 (a) Bilateral gynecomastia treated in two stages. (b) This case,
like that of Figure 8, required mastopexy. Final result is good following
liposuction and glandular resection in two successive operations one
year apart

b
a b

Fig. 8 (a) Bilateral gynecomastia with aggressive liposuction and Fig. 10 (a) 30 year old male with appearance of female breasts but
resection of glandular tissue done twice (one year apart) with satisfac- this actually represents ptosis as a result of extreme weight loss. The
tory results without skin resection and subsequent skin scarring. only solution is mastopexy leaving skin scarring. (b) One year post
(b) Final result one year postoperative from second operation mastopexy
Gynecomastia
a a
b
Fig. 11 (a) Gynecomastia with a predominantly glandular component.
In this case the glandular resection is of overriding importance.
Liposuction is used mainly to shape and soften the contours. (b) Two
years postoperative
b considered as a milestone in the treatment of gynecomas-
c
Fig. 12 (a) Minimal gynecomastia but significant enough to require
correction with conservative liposuction and glandular resection.
(b) One year postoperative. Breast proportion is normal, the slight
inframammary crese is gone, the nipple areola complex is spontane-
ously reduced both in diameter and in prominence
293
b
c
Fig. 13 (a) Severe gynecomastia in 18 year old male. (b) Two years
postoperative following combined liposuction and glandular resection
tia, and several authors now talk of a pre-liposuction and
a post-liposuction era. Liposuction is now the gold stan-
dard for the reduction of the fatty component, although
there remains a diversity of opinion on the same indica-
tion for the reduction of the glandular component. Some
surgeons state that liposuction can also treat the glandular
component by using special cannulas [7, 8, 22, 23].
However, most surgeons at present follow the policy of
removing fatty tissue with cannulas and the gland with a
scalpel. The most common access is the hemi-periareolar
one [24], although other access points, such as the axilla,
are used [18]. An alternative type of resection can be
used: (1) the glandular portion is resected and removed en
bloc; (2) the same is removed in pieces, seized with for-
ceps, and pulled through small incisions in the areolar
incision (pull-through technique) [9, 11, 14, 17]. Finally,
treatment for very severe forms inevitably involves exter-
nal incisions (Fig. 10), which can be limited to the infra-
mammary fold, can be performed in the inverted-T
fashion, and might require even a nipple-areola graft
294
(Thorek technique) as used for severe gigantomastias
[25–27].
Conclusions
For every type of gynecomastia, which can be classified
as specified herein, there is a suitable surgical approach.
When following this policy strictly it is possible, in most
cases, to obtain completely satisfactory results and restore
proper proportion and morphology to the male breasts
(Figs. 11, 12, and 13).
Bibliography
1. Cavina C, Cipriani R, Gallucci A, Maroni F (1993) Ginecomastia:
inquadramento clinico e terapia chirurgica. Riv Ital Chir Plast
25:147
2. Letterman G, Shurter M (1976) Gynecomastia. In: Courtiss EH
(ed) Male aesthetic surgery. Mosby, St. Louis
3. Davanço RA, Sabino Neto M, Garcia EB, Matsuoka PK, Huijsman
JP, Ferreira LM (2009) Quality of life in the surgical treatment of
gynecomastia. Aesthetic Plast Surg 33:514–517
4. Cho YR, Jonhs S, Gosain AK (2008) Neurofibromatosis: a cause of
prepubertal gynecomastia. Plast Reconstr Surg 121:34e–40e
5. Simon BE, Hoffman S, Kahn S (1973) Classification and surgical
correction of gynecomastia. Plast Reconstr Surg 51:48–52
6. Letterman G, Schurter M (1984) Gynecomastia. In: Goldwin RM
(ed) The unfavorable result in plastic surgery: avoidance and treat-
ment, 2nd edn. Little Brown, Boston, pp 779–787
7. Aiache AE (1989) Surgical treatment of gynecomastia in the body
builder. Plast Reconstr Surg 83:61–66
8. Becker H (1990) The treatment of gynecomastia without sharp
excision. Ann Plast Surg 24:380–383
9. Bracaglia R, Fortunato R, Gentileschi S, Seccia A, Farallo E (2004)
Our experience with the so-called pull-through technique com-
bined with liposuction for management of gynecomastia. Ann Plast
Surg 53(1):22–26
10. Boljanovic S, Axellson CK, Elberg JJ (2003) Surgical treatment of
gynecomastia: liposuction combined with subcutaneous mastec-
tomy. Scand J Surg 92(2):160–162
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11. Hammond DC (2009) Surgical correction of gynecomastia. Plast
Reconstr Surg 124(1 Suppl):61e–68e
12. Hammond DC, Arnold JF, Simon AM, Capraro PA (2003) Combined
use of ultrasonic liposuction with the pull-trough technique for the
treatment on gynecomastia. Plast Reconstr Surg 112:891–895
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Al Mufti R (2008) Surgical management of gynecomastia: out-
comes from our experience. Breast 17:596–603
14. Lista F, Ahmad J (2008) Power assisted liposuction and the pull
through technique for the treatment of gynecomastia. Plast Reconstr
Surg 121:740–747
15. Mentz H, Ruiz-Razura A, Newall G, Patronella CK, Miniel LA
(2007) Correction of gynecomastia through a single puncture
incision. Aesthetic Plast Surg 31:244–249
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Plast Surg 18:815–822
17. Morselli PG (1996) Pull-through: a new technique for breast
reduction in gynecomastia. Plast Reconstr Surg 97:450–454
18. Ohyama T, Takada A, Fujikawa M, Hosokawa K (1998) Endoscope-
assisted transaxillary removal of glandular tissue in gynecomastia.
Ann Plast Surg 40:62–64
19. Persichetti P, Berloco M, Muccioli Casadei R, Marangi GF, Di
Lella F, Nobili AM (2001) Gynecomastia and the complete circum-
areolar approach in the surgical management of skin redundancy.
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adolescent gynecomastia using a bipedicle technique. Ann Plast
Surg 40:241–245
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108:348–351
 Reoperative Aesthetic Breast Surgery
James C. Grotting and Michael S. Hanemann Jr.
1 Introduction
Reoperative aesthetic breast surgery is a vast topic, the
breadth of which would be covered more appropriately by an
entire textbook than by a single chapter. There are an endless
number of different unfavorable situations that can result
from the surgical enhancement or alteration of the breasts,
and likewise a countless variety of techniques that can be
used to treat these problems. As such, the focus of this chap-
ter is to review some of the principles that may guide the
plastic surgeon in treating some of the more common prob-
lems seen after breast augmentation, mastopexy, and reduc-
tion mammaplasty. Clinical examples illustrating the
correction of specific problems are presented.
According to recent prospective data, aesthetic breast sur-
gery is very safe, as evidenced by low rates of significant
complications. A study analyzing more than 13,000 consec-
utive aesthetic breast surgical procedures performed over a
1-year period showed that the readmission rate for treatment
of complications is extremely low (1.8 %). Six-year prospec-
tive data of more than 51,000 consecutive aesthetic breast
surgical procedures performed between 2003 and 2009
report readmission rates for infection specifically to be less
than 1 % (0.2 %) [1].
In 2008, breast augmentation surpassed liposuction as the
most commonly performed cosmetic surgical procedure in
the United States [2]. Unfortunately, not all breast augmenta-
tions result in outcomes that are satisfactory to the patient.
Breast augmentation sets in motion a dynamic relationship
between the implant and the surrounding soft and hard tis-
sues. Moreover, prosthetic implants can precipitate signifi-
J.C. Grotting, MD, FACS (*)
Private Practice, Grotting Plastic Surgery, Birmingham, AL, USA
e-mail: FACSjcgrotting@aol.com
M.S. Hanemann Jr., MD
Private Practice, Hanemann Plastic Surgery,
Baton Rouge, LA, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_22
cant tissue changes in the breasts over time, which may
transform what was once a favorable result into an unfavor-
able one. Accurate diagnosis of the unsatisfactory result after
aesthetic breast surgery is prerequisite to its treatment and
correction.
The fundamentals of delicate handling of tissue, knowl-
edge of the ideal beautiful normal, understanding of surgical
anatomy, and respect for blood supply and innervation are
dogmas in reoperative aesthetic breast surgery. Perhaps the
best way to begin a discussion of this form of surgery is to
review common complications and their treatment. To avoid
redundancy, “pearls and pitfalls” are marked in boldface
throughout the chapter.
2 Acute Complications
2.1 Hematoma
Postoperative bleeding in the implant pocket after breast
augmentation can lead to hematoma. Small amounts of blood
can be observed; however, large hematomas should be surgi-
cally evacuated in the operating room under sterile condi-
tions (Fig. 1). Periprosthetic hematoma has been associated
with increased risk of both subclinical infection and capsular
contracture [3]. Large outcome studies report hematoma
rates of less than 2 % [4]. Suspicion should arise if there is
unilateral pain, new volume discrepancy, or extensive
ecchymosis of the skin following breast augmentation.
Reoperation for significant hematoma should consist of
implant removal, clot evacuation, pocket irrigation, identifi-
cation of the causative vessel (if possible), meticulous
hemostasis, reirrigation, implant replacement, and incision
reclosure. Hematoma risk can be minimized by precise con-
trol of hemostasis under direct, lit vision during the primary
operation and by having patients refrain, for at least 1 week
preoperatively, from taking medications or supplements
known to affect normal coagulation, such as aspirin, other
nonsteroidal anti-inflammatory drugs, and vitamin E.
295
296
Fig. 1 Case presentation 1. Large hematoma following primary breast
augmentation, which presented as pain, swelling, and ecchymosis
Hematoma is less common and usually has less severe
consequences in mastopexy and breast reduction. However,
any sizeable clot or fluid collection can cause ischemia of
the nipple–areolar complex (NAC) through compressive
effect.
2.2 Infection
Infection is an uncommon but potentially serious complica-
tion of breast augmentation, with a quoted incidence of
1–4 % [4], but most series in the literature reportrates
between 1 and 2 % [5, 6]. Staphylococcus aureus and
Staphylococcus epidermidis are most frequently the caus-
ative organisms [7]. Infections attributable to Pseudomonas
aeruginosa typically present with low-grade fever and pain
out of proportion to physical examination findings [8]. A
comparative analysis of more than 1,600 primary augmenta-
tion mammaplasties concluded that a single intravenous dose
of perioperative antibiotics is adequate for prophylaxis in
breast augmentation surgery, and that further oral antibiotic
coverage postoperatively does not result in reduced superfi-
cial or periprosthetic infections [9]. Pfeiffer et al. [10] con-
cluded that intraoperative antibacterial lavage resulted in
lower rates of both infection and seroma10. Although super-
ficial cellulitis and mild infection may respond to oral or
intravenous antibiotics, the presence of frank purulence
mandates removal of the implant [11, 12].
Infection following mastopexy and breast reduction is
slightly more common but tends to be far less problematic
than infection in cases where an implant is used. Unless an
abscess develops, soft-tissue cellulitis following these proce-
dures nearly always resolves with a short course of oral
antibiotics. It is important to ensure that an undrained seroma
is not a factor contributing to ongoing cellulitis. The pres-
ence of a seroma can produce lower-pole erythema even in
the absence of infection.
J.C. Grotting and M.S. Hanemann Jr.
2.3 Seroma
Seroma after primary breast augmentation is rare and usu-
ally self-limiting. Problematic seromas occur more fre-
quently following revision implant surgery, especially
after capsulectomy or extensive capsulotomy. Aspiration
should be considered only if the seroma is palpable or bal-
lotable, such that it can be reached without puncturing the
implant [13].
Aspiration should be performed through the skin of
the lateral aspect of the breast at the most dependent
aspect of the seroma, with the patient in the lateral decu-
bitus position, while manually protecting the implant by
displacing it medially. We routinely leave a closed suction
drain postoperatively when performing significant modifica-
tions to the capsule.
Large, periprosthetic seromas that occur more than
30 days postoperatively are considered chronic, and should
be drained in the operating room under sterile conditions. A
short, lateral segment of the original incision can be reopened,
followed by evacuation of seroma, irrigation, and placement
of a closed suction drain. If a chronic thickened seroma wall
or capsule is encountered, it should be resected. Deciding
upon the timing of drain removal can prove difficult, espe-
cially when a significant amount of drainage persists.
Removing the drain too early can result in reaccumulation of
fluid, yet leaving the drain for a protracted length of time
risks the introduction of infection into the pocket.
Most American plastic surgeons choose not to drain pri-
mary breast augmentations and augmentation mastopexies.
Whether to leave drains following mastopexy and breast
reduction depends on surgeon preference. Studies have
shown that drain placement does not decrease seroma rates
in these primary procedures [14]. We prefer to leave a drain
when significant liposuction of the breast or lateral axillary
roll has been performed, as this appears to contribute to
seroma formation.
2.4 Wound Dehiscence and Skin Necrosis
Wound dehiscence within the first postoperative week is usu-
ally due to technical error of the closure or selection of an
implant that is too large. It is important to approximate the
superficial fascial system (SFS) of the breast, especially
when an inframammary incision is used, because the
force from the weight of the implant is transmitted
directly to the incision. In addition, closure of the SFS layer
provides necessary soft-tissue coverage of the inferior aspect
of the implant. If dehiscence occurs within a few days of
implant placement, the patient can usually be returned to the
operating room and the implant salvaged by irrigating the
Reoperative Aesthetic Breast Surgery
pocket and carefully reclosing the wound in layers. When
dehiscence occurs later than a week postoperatively, infec-
tion (with or without seroma) should be suspected as the
cause. Implant removal is often required to clear the infec-
tion. In select cases, the implant can be salvaged by thorough
irrigation of the pocket with antibiotic solution, replacement
of the implant, reclosure of the wound, and intravenous anti-
biotic therapy [15].
Wound-healing complication rates have been reported to
be between 3 and 50 % in breast reduction [16]. Such a wide
variation in the range of wound-healing complication rates
exists for multiple reasons. Different studies have different
inclusion criteria for what is considered a complication. In
addition, there is wide variation of patient populations and
techniques used in mastopexy and breast reduction. Most
wound-healing complications are related to excessive ten-
sion on the closure and can be treated effectively with local
wound care. Wound dehiscence or skin necrosis secondary to
excess tension on the closure is significantly more problem-
atic after revision augmentation mastopexy because of the
risk of implant exposure. Placement of an implant poten-
tially alters the blood supply to the NAC. Techniques that
involve wide skin undermining should be avoided in revi-
sion augmentation mastopexy, especially if the original
augmentation was in the subglandular plane. Blood sup-
ply must constantly be in the surgeon’s mind during all revi-
sional or reoperative breast surgery.
2.5 Fat Necrosis
Primarily seen after reduction mammaplasty, fat necrosis
occurs as a result of compromised perfusion to the fatty com-
ponent of the breast parenchyma. Fat necrosis confounds
physical examination of the breast, as it can manifest as a firm,
discrete mass. Mammography interpretation is affected by fat
necrosis, as it may appear as a solid mass associated with radi-
opaque calcifications. Discrete areas of fat necrosis often
require excision. This can usually be done remotely through a
pre-existing scar. We prefer to wait 9–12 months before mak-
ing a decision to reoperate for fat necrosis, as it is impressive
how often early firmness will resolve given enough time.
2.6 Nipple–Areolar Complex Necrosis
Perhaps the most feared complication of revision mastopexy
or breast reduction is partial or total loss of the NAC. Careful
preoperative planning, with particular attention to how the
previous surgery might have altered blood supply, is essen-
tial to safely preserve the NAC. It should be routine practice
to study the previous surgeon’s operative report to determine
297
which technique and pedicle were used. Reuse of the same
pedicle used in the previous surgery is the safest way to
proceed in revision surgery. When the previous operative
record is unavailable or the previous pedicle is unknown, the
reoperative plan should maximize preservation of blood sup-
ply to the NAC. Safe options for consideration include the
use of bipedicled techniques, or breast reduction by liposuc-
tion alone with skin-only mastopexy.
Perfusion of the NAC should be continually reassessed
intraoperatively. One should be aware of the amount of ten-
sion placed on the dermatoglandular pedicle during nipple
inset. If it becomes apparent that the NAC will not sur-
vive because of ischemia, the surgeon should consider
converting to free composite nipple grafting intraopera-
tively. Although grafted nipples have a higher incidence of
projection loss and depigmentation, these sequelae are pref-
erable to frank necrosis.
To avoid nipple–areolar loss, mastopexy and breast reduc-
tion techniques that involve wide undermining of skin flaps
should not be used in revision cases where the integrity of
the pectoralis muscle perforators is in question. Should
necrosis occur in the NAC, debridement of necrotic tissue
should be followed by local wound care to encourage healing
by secondary intention. After the tissues have healed and
softened, local flaps composed of scar tissue can be used for
nipple reconstruction, followed by areolar tattooing (Fig. 2).
3 The Unfavorable Result
As acute complications are relatively rare, reoperation after
aesthetic breast surgery is more commonly sought to improve
an early or late result that is not satisfactory to the patient.
The plastic surgeon can most effectively avoid reoperation
by patient education, accurate diagnosis, careful preopera-
tive planning, skillful technical execution of the primary
operation, and diligent postoperative care. Revision surgery
to correct an unfavorable result of breast augmentation, mas-
topexy, or reduction can be extremely challenging.
It is essential to ascertain exactly what concerns the
patient. Her chief complaint should be stated as specifically
as possible. Does the patient dislike the breast size, shape,
asymmetry, nipple position, inframammary fold definition,
degree of ptosis, rippling, or implant palpability? Was she at
any time pleased with the result of her previous surgery? The
more focused is the patient’s and surgeon’s common objec-
tive, the more likely they are to achieve this goal. One must
beware of the patient who is unable to clearly articulate spe-
cifically what is displeasing to her about her breasts.
Unsolicited pejorative comments about a previous sur-
geon may provide insight as to whether the patient is likely
298 J.C. Grotting and M.S. Hanemann Jr.

a b

c d

Fig. 2 Case presentation 2. NAC necrosis. (a) Nipple–areolar necrosis reported by Spear et al. in a patient with sickle cell trait [17].
in a patient with sickle cell trait who underwent vertical breast reduc- (b) Complete nipple–areolar necrosis necessitated serial debridement. (c)
tion. Interestingly, the necrosis appeared at 14 days postoperatively, Healing by secondary intention at 1 year postoperatively. (d) Long-term
after initial satisfactory perfusion. A similar observation has been result after nipple reconstruction with local flaps and areolar tattooing

to be satisfied with revision surgery. It is important to assess Table 1 Reoperation rates: industry core study data for silicone-filled
patient expectations and to determine whether these expecta- breast implants
tions are realistic and whether they are likely to be met. The 6-year data Mentor Allergan
surgeon should help the patient set realistic expectations by Primary augmentation 19.4 % (N = 551) 30.1 % (N = 755)
educating her about what is and what is not possible as per- Revision augmentation 34.2 % (N = 146) 40.5 % (N = 147)
tains to her specific anatomy.
The timing of reoperation is an important clinical deci-
sion that requires patience, judgment, and experience. The 4 Implant Malposition
importance of delaying reoperation until scars have soft-
ened, edema has subsided, skin color has returned to Implant malposition is not infrequently seen following breast
normal, and tissues have achieved equilibrium cannot be augmentation. It can be precipitated by technical error, poor
overemphasized. The surgeon should discuss the risks, judgment in planning, inappropriate implant selection,
benefits, and possible outcomes of the planned procedure development of capsular contracture, inability of the patient’s
with the patient and, if possible, with her significant other. soft tissues to support the implant, or any combination of
Reoperation rates following primary and revision breast these. Ideally, implant malposition can be detected at time of
augmentation with silicone implants are listed in Table 1. the initial procedure and immediately corrected, although
Reoperative Aesthetic Breast Surgery
a b
Fig. 3 Case presentation 3. Inferior implant malposition following
bilateral augmentation with vertical mastopexies. (a) Involutional post-
partum atrophy with grade 3 ptosis treated with augmentation and
usually malposition does not become evident until the pocket
has had time to mature.
Malposition is often multifactorial, may be multidirec-
tional, and is influenced by both intrinsic properties of the
implant (dimensions, volume, surface texture characteris-
tics) and patient characteristics (skin quality, parenchymal
integrity, and age).
4.1 Inferior Malposition
Immediate inferior displacement of the implant can result
from pocket overdissection inferior to the inframammary
fold. If this problem is recognized intraoperatively, the sub-
cutaneous tissue of the inferior flap can be sutured to the
deep fascia of the chest wall to obliterate the space. A com-
pression garment or conforming underwire bra can be worn
postoperatively to maintain implant position during the heal-
ing phase [18].
If this problem is not diagnosed until later, reoperation
may be necessary. Inferior capsulorrhaphy is the mainstay of
reoperation for inferior implant malposition. The use of
acellular dermal matrix has been described to reinforce cap-
sulorrhaphy in order to correct the various types of implant
malposition [19]. One should remember that lowering the
position of the inferior pole of the implant causes not only
299
vertical mastopexy. (b) Note the apparent NAC elevation that occurs
with implant descent
descent of the implant but also an apparent elevation of the
NAC in relation to the implant (Fig. 3).
Occasionally, reoperation may be averted by a simple
suture technique that can be performed in the office under
local anesthesia. Scarpa’s fascia/superficial fascia system
(SFS) is percutaneously sutured to the deep muscle fascia
with 2.0 Prolene on a large needle in multiple places along the
desired level of the inframammary fold through small stab
incisions. The needle is passed into a stab incision and catches
the deep muscle fascia, and the tip is brought out through the
skin of an adjacent stab incision. The needle is then placed
back through the second stab incision and passed subcutane-
ously toward the original stab incision. It is then brought out
through the original stab incision. When the knot is then tied,
the SFS is anchored to the chest wall fascia, setting the posi-
tion of the new inframammary fold [11] (Figs. 4 and 5).
4.2 The Double-Bubble Deformity
Submuscular placement of an implant that is too large for
the dimensions of the breast in a patient with a tight infra-
mammary fold may lead to a specific type of inferior
implant malposition known as a double-bubble deformity.
This deformity is characterized by the persistence of the
original inframammary fold as a visible curvilinear inden-
300
tation, exacerbated by the original attachments of the pec-
toralis muscle along the original fold. It lies superior to the
inferior margin of the breast implant. To correct this defor-
mity, the implant can removed and replaced with a smaller
device, and the original inframammary fold can be reap-
proximated to the chest wall by capsulorrhaphy [20]. A sec-
ond method entails the complete obliteration of the
Fig. 4 Percutaneous suture technique for elevation of the inframam-
mary fold. View of inferior aspect of breast with the patient supine
a b
Fig. 6 Case presentation 4. Correction of double-bubble deformity
with planned implant deflation following saline augmentation.
(a) Right double-bubble deformity after submuscular augmentation
J.C. Grotting and M.S. Hanemann Jr.
intermeshed fibers between the dermis and SFS of the orig-
inal inframammary fold. This is a more difficult technique,
and quite often some perceptible remnant of the original
fold persists and remains dissatisfying to the patient [21].
Another option to correct the deformity is to convert the
implant to the subglandular plane, with or without preop-
erative deflation of the implants (Fig. 6).
Fig. 5 Percutaneous suture technique for elevation of inframammary
fold (plication of the Scarpa’s fascia/superficial fascia system to the
chest wall)
c
with saline implants. (b) After in-office deflation, the deformity is noted
bilaterally. (c) After conversion to silicone implants in the subglandular
plane
Reoperative Aesthetic Breast Surgery
4.3 Lateral Malposition
Lateral malposition should be additionally assessed by
examining the patient lying supine and while standing with
her shoulders abducted greater than 90°. Lateral displace-
ment of the implants is accentuated in these positions. Lateral
malposition is usually due to technical error at the time of
primary augmentation, and can be avoided by selection of an
appropriately sized implant and precise pocket dissection
that does not extend lateral to the lateral breast border. Once
the implant is placed, gentle finger dissection lateral to the
implant can smooth out the contour of the lateral breast bor-
der by releasing constricting bands of the overlying breast
tissue. Correction of lateral malposition generally requires
surgical intervention, with the goal of the procedure being to
obliterate the lateral recess of an excessively large lateral
periprosthetic capsular space [21]. Of course, lateral malpo-
sition can also evolve as a result of placing a large implant
with a mass that exceeds the abilities of the soft tissues to
support it long term. It is a misconception that subpectoral
pockets allow the muscle to “support” the implant over time.
In fact, the constant contraction of the pectoralis over time
may well contribute to downward and outward displacement
of the device.
In summary, caution must always be exercised during lat-
eral pocket dissection at the time of primary or revision aug-
mentation, for several reasons. First, overdissection of the
lateral breast pocket can efface the contour of the lateral
breast border. Second, for subpectoral implants, muscular
contractions of the pectoralis major tend to force the implant
inferolaterally and can contribute to lateral malposition over
time. Third, sharp or electrocautery dissection lateral to the
lateral border of the pectoralis major muscle places the lat-
eral branch of the fourth intercostal nerve at risk for injury,
which can lead to nipple desensitization. Attention to these
details will minimize the need for reoperation.
Various lateral capsulorrhaphy techniques have proved
effective for medialization of the implant. Lateral malposi-
tion may be corrected with a site change of the implant
pocket (either subglandular to submuscular, or submuscular
to subglandular). Maxwell et al. have described correction of
lateral, medial, and inferior implant malposition by reposi-
tioning of the implant in a neosubpectoral pocket [22]. This
technique refers to development of a new pocket for the
implant below the pectoralis major muscle but on top of the
anterior dome of the previous implant capsule. Alternatively,
if previous implants have been in both the subglandular and
subpectoral planes, the new pocket can be developed on top
of the pectoralis major muscle, but behind the posterior wall
of the subglandular capsule.
When performing capsulorrhaphy, we prefer to score with
electrocautery both the mobile surface of the capsule and the
fixed surface of the capsule along the chest wall at the site of
301
planned suture line. The capsulorrhaphy line should be
placed at the desired location of the lateral breast border, as
this is where the lateral aspect of the implant will lie. We use
a 2.0 Prolene suture on a CT-1 taper needle with a small loop
tied at one end. The needle is passed through the fixed and
then through the mobile capsule at the superior extent of the
planned junction of the lateral breast border and chest wall.
The needle is then passed through the loop, and the loop is
cinched down in lieu of tying a knot. This obviates cumber-
some knot tying in an area of limited accessibility through a
limited incision. The capsulorrhaphy proceeds by advancing
the needle in a superior to inferior direction through the
scored fixed and mobile capsule. The knot is tied at the infe-
rior limit of the capsulorrhaphy, which is easily accessible
through an inframammary incision. If the knot cannot be
buried, the tails of the suture are left long to prevent rigid
suture material from being in contact with the implant.
4.4 Medial Malposition/Synmastia
When the implant pockets are positioned too close together,
a condition known as synmastia (also known as symmastia)
can result. Synmastia is most commonly caused by overag-
gressive division of the parasternal origins of the pectoralis
major muscle, and can be quite challenging to correct. If syn-
mastia has occurred with implants in a subglandular plane,
transition to the submuscular plane and leaving the paraster-
nal origins of the pectoralis major muscle intact may correct
the problem. Maxwell et al. and Spear et al. have indepen-
dently described correction of synmastia and other forms of
implant malposition using an accurately dissected neosub-
pectoral pocket for implant placement (Fig. 7) [22, 23].
Other techniques have been described, which entail reap-
proximation of the medial breast SFS to the deep muscle fas-
cia or the perichondrium of the ribs [11].
4.5 Superior Malposition
The superior extent of the breast can be better visualized by
gently compressing the breast mound toward its base, which
will demarcate the junction between the superior pole of the
breast and the skin of the chest wall. There is rarely an indi-
cation in primary breast augmentation to dissect the pocket
superior to this anatomic junction, as doing so can result in
superior implant malposition. Inadequate inferior pocket
dissection and failure to release the inferior attachments of
the pectoralis major muscle to the chest wall (in a submus-
cular augmentation) can also lead to superior malposition.
Failure to visualize and divide these muscle attachments is
why non-endoscope-assisted transaxillary breast augmenta-
tions are fraught with a higher incidence of superior implant
302 J.C. Grotting and M.S. Hanemann Jr.

a b

Fig. 7 Case presentation 5. Correction of synmastia. (a) Synmastia, ptosis, and flattening of the inferomedial left breast contour after submuscular
saline augmentation. (b) Correction of synmastia with placement of silicone implants in a neosubmuscular pocket with vertical mastopexy

a b

Fig. 8 Case presentation 6. Superior implant malposition of right breast. (a) Right superior implant malposition after submuscular saline augmen-
tation. Markings of planned capsulotomies. (b) After appropriate lowering of the right IMF by inferior capsulotomy

malposition (Fig. 8). Elastic wrapping of the superior poles
of the breasts may help maintain implant position after cor-
rection of superior malposition (Fig. 9).
5 Size Change
A request for a size change may be secondary to inappropri-
ate implant selection to meet the patient’s expectations at the
previous surgery, or simply due to the patient’s changing her
mind about size after the fact. Longevity of the satisfactory
breast augmentation result can be increased by selecting
an implant that is well proportioned to the patient’s
breast and body size. Smaller implants are tolerated better
by the breast tissues over time. One should educate the
patient who wishes to be disproportionately large about the
deleterious effects oversized implants can have on the breasts
over time.
Factors such as weight fluctuation and hormonal influ-
ences resulting from pregnancy and lactation may change the
appearance of previously lifted or reduced breasts such that
revision mastopexy or breast reduction may be indicated.
Reoperative Aesthetic Breast Surgery
a b
Fig. 9 Case presentation 7. Right inferior implant malposition and left
superior implant malposition secondary to capsular contracture.
(a) Status post submuscular augmentation with silicone implants
The original operative reports should be reviewed and the
original pedicle respected to avoid devascularization of the
NAC. Most secondary reductions are modest in relation to
the volume removed at the initial procedure. To avoid over-
resection in breast reduction, more attention should be
paid to the amount of breast tissue left behind than to the
amount of tissue resected [11].
For patients who desire a larger or smaller size, it is ben-
eficial to obtain the original operative report to determine the
exact volume, dimensions, shape, surface characteristics,
and position of the current implants. Sizers may help with
intraoperative decision making, especially if the replacement
implants are fixed-volume silicone-filled devices. If the new
implants are saline, the surgeon is afforded some latitude for
volume adjustment by the ability to fill the implants to differ-
ent volumes intraoperatively. If the patient wishes to go from
a larger to a significantly smaller size, one should consider
staging the procedures. This will allow for retraction and
recovery of the breast tissues between explantation and reim-
plantation (Fig. 10).
Occasionally a patient will have undergone previous aug-
mentation or augmentation mastopexy with implants that are
obviously too large, with the result grossly asymmetric and
unsatisfactory to the patient. We have found that such patients
are good candidates for percutaneous deflation of the implants
in the office about 30 days prior to definitive surgical correc-
tion. Preoperative deflation allows the surgeon to “make
sense” of the deformity by allowing “recovery” of the
stretched gland by the shortening of suspensory liga-
ments. The amount of residual breast tissue and the degree of
ptosis can be better assessed after deflation (Fig. 11).
A small amount of local anesthetic is injected in the lower
pole of the breast, as the implant is manually displaced inferi-
orly. After the skin is prepped with Betadine solution, an
18-gauge needle is inserted through the skin, into the implant,
and the saline is evacuated with suction. The exact volume of
303
c
through inferior periareolar incisions. (b) Shoulder abduction accentu-
ates the asymmetry and implant malposition. (c) After capsulotomies,
placement of larger implants, and right inferior capsulorrhaphy
saline can be ascertained in this manner, which can be helpful
in the planning of the definitive procedure, especially when
records from the previous surgery are unavailable (Fig. 12).
Some women find that they are satisfied with the residual
volumes of their native breast tissue. If the post-deflation
patient with ptosis can make her breasts look the way she
wants in a brassiere, the implants are removed, and bilateral
mastopexies are performed without replacement of an
implant. If the ptotic, post-deflation patient would like to be
a larger size, implants are removed and replaced with appro-
priately sized silicone implants in the subglandular, subfas-
cial, or neosubmuscular plane.
6 Ptosis
The aesthetic goals of breast reduction and mastopexy are
similar: to produce symmetric, well-shaped breasts, with
sensate, appropriately sized and positioned NACs, with lim-
ited scarring.
Women with significant breast ptosis frequently present
requesting only breast augmentation. When a lift is recom-
mended, most women are initially loath to accept the addi-
tional scarring associated with mastopexy. Although every
patient would prefer to limit scarring on her breasts, it is the
responsibility of the plastic surgeon to educate the patient on
the aesthetic limitations of augmentation alone for enhance-
ment of the ptotic breast. The trade-off with adding masto-
pexy to an augmentation is improved breast shape for
increased scar burden. Although traditionally staged, aug-
mentation and mastopexy have for some time been routinely
combined in both primary and revision aesthetic cases. In
experienced hands, augmentation mastopexy can yield pre-
dictable and satisfactory results.
Attempting to place a large implant to “fill up the loose
skin envelope” of a ptotic breast is a practice not uncommonly
304
a b
Fig. 10 Case presentation 8. Downsizing of implants following
in-office deflation of saline implants. (a) Patient feels that she is too
large following submuscular saline breast augmentation (IMF
incisions). (b) Immediately following in-office deflation of saline
seen but inherently flawed in principle. Doing so takes a sig-
nificant toll on the breast tissues and will invariably lead to
implant-related complications, a displeasing long-term cos-
metic result, and eventual reoperation.
When an implant (typically in the submuscular plane) is
positioned appropriately on the chest wall in the ptotic breast,
and the breast tissue droops off the inferior edge of the
implant, the resulting deformity has been described in the
United States as a “Snoopy” deformity, because its appearance
resembles the nose of the famous comic-strip beagle of the
same name. It is also known as a “waterfall” deformity
J.C. Grotting and M.S. Hanemann Jr.
c
implants. Operative procedures were staged 30 days apart to allow
for recovery of breast tissues and retraction of the pockets. (c) After
deflated implant removal and replacement with smaller submuscular
saline implants
(Fig. 13) [20, 24]. This deformity is more pronounced if the
inferomedial attachments of the pectoralis major muscle to
the chest wall have not been divided [20, 24, 25]. If the
patient has an adequate amount of native breast tissue, a sili-
cone implant can be transitioned into the subglandular plane,
and if ptosis persists, a simultaneous mastopexy can be per-
formed. If the patient’s pinch thickness precludes placement
of a subglandular implant, the inferomedial pectoralis mus-
cle origins should be divided (if they have not been already),
and a mastopexy should be performed to lift the ptotic breast
(Fig. 14).
Reoperative Aesthetic Breast Surgery 305

Fig. 11 Case presentation 9. Severe asymmetry following (b) After in-office deflation of saline implants. (c) After replacement
augmentation with periareolar mastopexy. (a) Following submuscular with smaller, textured, subglandular silicone implants
augmentation with saline implants and periareolar mastopexies.

Fig. 12 Case presentation 10. In-office deflation of saline implant

306 J.C. Grotting and M.S. Hanemann Jr.

Fig. 13 Case presentation 11. “Snoopy” or “waterfall” deformity. (a) total capsulectomies, replacement with silicone implants in the sub-
Submuscular silicone implants in a former bodybuilder. The ptotic glandular plane, and vertical mastopexies
gland falls off the inferior edge of the implant. (b) Removal of implants,

Fig. 14 Case presentation 12. “Snoopy” or “waterfall” deformity. (a) implant. (b) After removal of implants and replacement with silicone
The patient underwent transaxillary submuscular augmentation with implants in the subglandular plane with periareolar mastopexy
saline implants. The ptotic gland hangs off the inferior edge of the
Reoperative Aesthetic Breast Surgery
Subglandular implant placement has been shown to
afford a slight degree of lift in the patient with mild ptosis.
One must exercise caution, however, in attempting to cor-
rect a moderately ptotic breast with a subglandular aug-
mentation without mastopexy. When a subglandular
implant settles in the most dependent portion of the ptotic
breast, anterior and inferior to the level of the preserved
inframammary fold, the resulting deformity resembles a
“rock in a sock,” and has been colloquially described as
such. Correction of this deformity can be achieved by relo-
cating the implant in the submuscular plane and performing
a simultaneous mastopexy to reposition the breast tissues
around the now appropriately positioned implant. Some
surgeons may choose to stage the procedures by removing
the implant, performing a mastopexy, and then placing a
new implant at a later time.
Fig. 15 The spectrum of breast asymmetry
307
7 Asymmetry
A comprehensive discussion of the correction of asymmetry
between operated breasts is beyond the scope of this chapter.
The surgical correction of breast asymmetry has been shown to
improve health-related quality of life and self-esteem [26].
Unless the patient’s original preoperative photographs are
available, it is often difficult, if not impossible, to determine
whether current asymmetries predated the last surgery or
whether they were caused by the procedure. The importance
of reviewing preoperative photos and pre-existing asymme-
tries with each patient prior to primary or revision aes-
thetic breast surgery cannot be overemphasized. Asymmetry
is the norm, not the exception, and has been reported to occur
as much as 88 % of the time [27]. It may be classified as chest
wall, breast mound, and NAC asymmetry (Fig. 15).
308
7.1 Chest Wall Asymmetry
The right and left hemithorax should be examined for skeletal
asymmetries and chest wall deformities, such as pectus exca-
vatum and pectus carinatum. Anatomic differences between
the right and left chest wall have been reported to occur in 9 %
of women undergoing breast augmentation. Chest wall asym-
metry can exacerbate the appearance of asymmetry of the
overlying breasts. Breast augmentation alone may not be able
to camouflage the chest wall deformity [28, 29].
7.2 Breast Mound Asymmetry
When comparing differences between the right and left
breasts, one should first examine the two sides for symmetry
in relation to the position of their foundations on the chest
wall. The base of the breast is a two-dimensional ovoid “foot-
print,” the horizontal boundaries of which are the superior
breast border and inframammary fold. Its vertical dimensions
are defined by intersection of the medial and lateral breast bor-
ders with the chest wall. Just as the base of the breast is defined
by its position on the chest wall, the shape of the breast mound
is defined by what extends above the chest wall.
A three-dimensional approach should be considered when
attempting to restore symmetry in aesthetic or reconstructive
breast surgery [30]. The shape, volume, projection, base diam-
eter, vertical height, and relative position on the chest wall
should be noted and compared. The nipple should be the most
projecting point of the breast, and is ideally positioned between
one-third and one-half the distance from the IMF to the upper
breast border. Mound asymmetry has been reported to occur in
44 % (volume), 29 % (base diameter), and 30 % (inframam-
mary fold position) of patients, according to a retrospective
analysis of 100 women undergoing breast augmentation [27].
The next step is to determine which side, if either, is nor-
mal. A common approach for correction of asymmetry is to
alter the less aesthetic side to match the more aesthetic side.
The fewer variables that are altered surgically, the more
predictable the result. Achieving symmetry is more pre-
dictable when the ultimate correction is accomplished
with the same combination of parenchymal volume and
implant [11]. Our approach to achieving symmetry in aug-
mentation mastopexy of breasts with significantly different
volumes is to reduce the larger breast to the same volume as
the smaller, and to place identical implants bilaterally.
7.3 Nipple–Areolar Complex Asymmetry
The shape and size of one NAC may be different from these
dimensions of the contralateral NAC as often as 53 % of the
time [27]. Areolar size and shape discrepancies and unsightly
J.C. Grotting and M.S. Hanemann Jr.
periareolar scarring can usually be corrected by simply
reducing each NAC with identical areolar markers and then
reinserting the areolae.
The two NACs may lie in different positions relative to
their respective ipsilateral breast mounds. Ideally, the implant
should be centered behind the NAC.
One NAC may demonstrate asymmetry from the contra-
lateral side in regard to its position on the chest wall. For
example, the distance from a fixed landmark on the chest
wall, such as the sternal notch, to each NAC should be equal.
The superior areolar border to suprasternal notch distance
and the medial areolar border to vertical midline distance are
important measurements for assessing symmetry. Generally
it is considered more important for overall breast aes-
thetics for each NAC to be centered in relation to its own
breast mound, than for the two NACs to be positioned
symmetrically in relation to a fixed landmark on the
chest wall.
Corrections of minor inferior, lateral, or medial displace-
ment of the NAC in relation to the chest wall may be achieved
with simple crescentic or circumferential, eccentric periareo-
lar de-epithelialization and reinserting techniques.
Superior NAC malposition is more difficult to correct,
as there is no way to increase the amount of skin between
the sternal notch and NAC, and it is considered unaesthetic
to place a vertical scar superior to the areola. Moderate
superior NAC malposition may be improved by shortening
the distance from the nipple to the inframammary fold by
direct excision of a horizontally oriented wedge of skin
and breast tissue along the inframammary fold. Correction
of severe superior NAC malposition may require free nip-
ple grafting.
8 Implant-Related Sequelae
(Capsular Contracture, Rippling,
Palpability, and Rupture)
8.1 Capsular Contracture
Capsular contracture is the formation of excessive scar tissue
around the breast implant, and is the most common unfavor-
able sequela of primary or revision breast augmentation. As
its occurrence can be unpredictable and its etiology is largely
unknown, it is perhaps one of the most frustrating implant
related problems for the patient and surgeon.
Rates of significant (Baker grade III or IV) capsular con-
tracture for silicone implants placed in the subglandular
plane have been reported to be around 30 % (Table 2). For
saline implants placed in the subglandular plane, this rate
drops to between 15 and 20 % [34, 35]. Submuscular place-
ment of implants has been reported to lower the rate of cap-
sular contracture. A possible explanation for this observation
Reoperative Aesthetic Breast Surgery 309

is that since submuscular implants have more soft-tissue
coverage than subglandular implants, breast distortion from
capsular contracture of a submuscular implant is more diffi-
cult to see and, therefore, to diagnose.
Advanced capsular contracture can effect unfavorable
changes in breast shape and appearance and can also cause
significant mastodynia. Many theories have been postulated
as to possible causes of capsular contracture, the most popu-
lar being blood in the implant pocket, biofilms, subclinical
infection [36, 37], and hypertrophic scar tissue formation
[38, 39]. Most significant capsular contracture is evident
by 1 year postoperatively, after which time it is relatively
uncommon for capsular contracture to progress [21]. In
separate prospective in vitro and clinical studies, Adams
et al. reported decreased incidence of capsular contracture
after irrigation of the breast pocket with povidone-iodine and
triple antibiotic solution at the time of augmentation [40, 41].
Treatment of capsular contracture now requires a direct
open approach, as the increasingly obsolete practice of
closed capsulotomy by manipulation is contraindicated
by the implant manufacturers [11].
Although some advocate extensive capsulotomies for
treatment of capsular contracture, we find that total capsulec-
tomy, with placement of a new implant, results in a lower
rate of recurrence. As previously mentioned, we leave a
closed suction drain in the pocket after subtotal or total cap-
sulectomy to prevent seroma formation (Fig. 16).

Table 2 Rates of grade II/IV capsular contracture: core study data for
silicone-filled breast implants [31–33]
8.2 Rippling, Wrinkling, Ridges, and Folds
6-year data Mentor Allergan
Primary augmentation 9.8 % (N = 551) 15.5 % (N = 755) Rippling (or wrinkling) is defined as a visible contour irregu-
Revision augmentation 22.4 % (N = 146) 20.4 % (N = 147) larity of the breast skin caused by folding of the underlying

a b

c d

Fig. 16 Case presentation 13. Correction of grade IV capsular contracture. (a) Right breast grade IV capsular contracture. (b) After capsulectomy,
implant removal, and replacement. (c) Calcified capsule. (d) Implant shape distortion secondary to capsular contracture
310
implant shell. The appearance of rippling can be exacerbated
by pectoralis muscle contracture and by the patient leaning
forward. The United States Food and Drug Administration
(FDA) 15-year moratorium (1992–2006) on the use of sili-
cone breast implants for aesthetic breast augmentation has
contributed to the increased incidence of rippling [42].
Multiple factors have been implicated in the cause of rip-
pling. It is more commonly seen in saline implants that are
filled below the manufacturer’s recommended minimum fill
volume (underfilling). Textured implants can exacerbate vis-
ible wrinkling because their surfaces are more adherent to
the overlying capsule and can exert traction on the overlying
skin. The degree of rippling is inversely proportional to the
viscosity of the filler substance. The amount of visible wrin-
kling is also inversely proportional to the thickness of the
patient’s soft-tissue cover. For example, underfilled, textured
saline implants in the subglandular position under thin breast
tissue have the highest likelihood of rippling. One way to
improve this scenario would be to remove the implants and
replace them with smooth silicone implants in the submus-
cular plane.
By contrast, what can be done to ameliorate persistent
upper pole rippling when the patient has smooth silicone
implants in the submuscular plane? Authors have described
the placement of an acellular dermal matrix (ADM) between
the implant and the capsule in cases of persistent visible
upper pole rippling. The ADM is thought to soften the
appearance of rippling by providing an additional layer of
soft-tissue cover over the implant [19].
Autologous fat injections between the skin and capsule
may be effective in reducing the severity of visible upper
pole rippling [43]. Fat injections as a method to improve con-
tour irregularities have been well described in breast recon-
struction and are increasingly becoming accepted as standard
treatment. However, as of this writing, the use of autologous
fat injections as an adjunctive treatment in aesthetic breast
surgery remains controversial.
Form-stable silicone breast implants, such as the Allergan
Style 410, have been available for non-experimental use out-
side of the United States for many years but have yet to be
approved by the FDA. Sampaio Góes [44] reported 0 % rota-
tion rate, decreased capsular contracture rates, and improved
aesthetic outcomes in breast augmentation with anatomic
form-stable silicone gel breast implants, when placed subfas-
cially. These implants show future promise in correcting dif-
ficult challenges such as correction of the “implant-crippled”
breast. Studies have shown that anatomically shaped, form-
stable gel breast implants demonstrated high rates of patient
satisfaction, long-term safety, and effectiveness [44].
We explain to all breast augmentation patients that their
implants will at some point be palpable through the skin, usu-
ally inferolaterally, where the soft-tissue cover is thinnest.
J.C. Grotting and M.S. Hanemann Jr.
8.3 Mechanical Failure of Implant
(Deflation/Rupture)
All breast implants are associated with some risk of device
failure. Cumulative 6-year rupture rates of Mentor
MemoryGel silicone implants for primary augmentation
were reported to be 1.1 % [32], whereas rupture rates for
Allergan (formerly Inamed) silicone implants were 3.5 %
over the same time period [33]. Capsular contracture may
increase the risk of implant rupture by creating folds in the
shell of the implant. Silicone that leaks outside of the capsule
can precipitate severe capsular contracture, infection, and
silicone granulomas, which can lead to hardening and defor-
mity of the breast.
9 Unacceptable Scar Formation
Hypertrophic scarring is uncommonly seen following breast
augmentation, and keloid formation is exceedingly rare.
Patients undergoing mastopexy or breast reduction have a
higher risk of hypertrophic scarring, thought to be related to
excessive tension on the closure. Patients with darker skin
types are historically more likely to develop hypertrophic
scars than those with lighter skin. Hypertrophic scarring can
be directly excised and reclosed, but this does not alleviate
the problem of excessive tension on the closure. Intermittent
intralesional steroid injections may improve the appearance
of hypertrophic scars, but may also cause problems with
hypopigmentation and fat atrophy.
10 Effects of an Implant on the Breast
Over Time
As a result of implant placement, the breast tissue undergoes
significant changes over time, including thinning and redis-
tribution of breast parenchyma, soft-tissue atrophy, stretch-
ing of the skin envelope, loss of dermal volume and elasticity,
and scarring. Weight fluctuation, pregnancy, and lactation
can further compound these changes. Implant placement
decreases blood supply to the breast parenchyma and NAC,
especially after subglandular augmentation.
The surgeon should be attuned to recognizing and
accounting for implant-related breast changes when plan-
ning a revision procedure. The reoperative breast surgeon
should be able to mentally visualize the altered underlying
breast anatomy, just as a rhinoplasty surgeon is able to pic-
ture the shape and configuration of the nasal framework
before aesthetic nasal surgery.
Reoperative Aesthetic Breast Surgery
Table 3 Risks and complications of reoperative aesthetic breast surgery
Acute complications Implant-related problems
Bleeding (hematoma) Implant exposure
Fluid collection (seroma) Rippling/palpability
Wound dehiscence Rupture (device failure)
Infection Malposition
Fat necrosis Silicone-associated problems
Nipple–areolar loss Capsular contracture
11 Informed Consent
For informed consent prior to reoperative aesthetic breast
surgery, we use the standard consent forms specific to each
procedure, endorsed by the American Society of Plastic
Surgeons. One should include as risks all of the acute com-
plications we describe in this chapter, along with the com-
mon causes of unfavorable cosmetic results. Specific
complications will vary among different procedures, and are
summarized in Table 3.
12 Summary
Reoperative aesthetic breast surgery can be challenging yet
rewarding. Research continues to establish the safety and
efficacy of both silicone and saline breast implants. The
results of these studies will affect the future surgical manage-
ment of women with breast implants. We expect that as sur-
gical techniques and implantable devices evolve, patient
satisfaction will remain high and reoperation rates can be
kept to a minimum. However, when the reoperative situation
presents, we can safely and satisfactorily improve upon it.
Whether for revision breast augmentation, mastopexy, or
reduction, the same sound fundamentals and principles of
plastic surgery apply [11].
Know the ideal beautiful normal. Diagnose what is present, what
is diseased, destroyed, displaced, or distorted, and what is in
excess. Then, guided by the normal in your mind’s eye, utilize
what you have to make what you want – and when possible go
for even better than what would have been [45]. Ralph Millard
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and Company, Boston
 Part III
Trunk and Extremities
 History of Aesthetic Surgery
of the Trunk and the Extremities
Giovanni Di Benedetto, Davide Talevi, Luca Grassetti,
and Aldo Bertani
Aesthetic surgery of the trunk and the extremities assuredly
represents the widest branch of aesthetic surgery of the body.
The main procedures used for trunk and extremity contour-
ing are abdominoplasty, brachioplasty, and thigh lift.
1 Abdominoplasty
Of the various aesthetic surgical procedures performed on
the trunk, abdominoplasty is the most common.
Abdominoplasty has undergone a significant evolution over
the past decades and still represents a widely performed pro-
cedure, despite the increasing popularity of liposuction,
which is less invasive and offers a more rapid recovery.
While it is difficult to identify the “father” of this technique,
we know that, historically, many surgeons started to perform
dermolipectomies of the abdominal wall to correct obesity
and to facilitate herniorrhaphy to repair umbilical hernias.
Toward the end of nineteenth century, three main tech-
niques gained popularity, utilizing different types of skin
incisions: transverse, vertical, reversed “T,” and crossed. In
1890, Demars [1] reported the first limited dermolipectomy
in France (Fig. 1a).
Soon after, in 1899, Kelly [2], a gynecologic surgeon, was
one of the first to attempt to correct excess abdominal skin
and fat. Using a transverse incision extending across both
flanks, he resected a panniculus of 7,450 g. Only 1 year later,
in 1900, he associated the term “aesthetic” with this kind of
procedure (Fig. 1b).
From then on several modifications were suggested and
several more cases were reported, mostly in Europe. The
G. Di Benedetto, MD, PhD (*) • A. Bertani, MD, PhD
Dipartimento di Scienze Mediche e Chirurgiche,
Università Politecnica delle Marche, Ancona, Italy
e-mail: dibenplast@hotmail.com
D. Talevi, MD • L. Grassetti, MD
Dipartimento di Chirurgia Plastica, Ricostruttiva ed Estetica,
Università Politecnica delle Marche, Ancona, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_23
French surgeons Gaudet and Morestin reported in 1905 the
repair of large hernias using a transverse incision of the
abdomen in conjunction with the resection of excess abdom-
inal skin and fat and preservation of the umbilicus. The
importance of the umbilicus as an aesthetic unit, however,
was introduced by Beck in 1917, who described a transverse
abdominoplasty with the re-raising of the umbilicus in the
center of the scar [3] (Fig. 1c).
In 1921, Frist performed the first repositioning of the
umbilicus above the transverse suture by tunnelization in an
abdominoplasty [4]. We can consider this step to represent
the birth of the modern technique of abdominoplasty
(Fig. 2a).
A few years later, in 1924, Thorek described a procedure
that preserved the umbilicus by using a half-moon excision
of the abdominal skin located under the umbilicus [5].
In 1940, Somalo performed abdominoplasty with a circu-
lar anteroposterior incision in a full reshaping of the torso
and the abdomen [6]. Other authors such as Pick [7] (1949),
Barsky [8] (1950), and Gonzales-Ulloa [9] (1960) described
a classic subumbilical lipectomy, the so-called belt lipec-
tomy. In 1967 Pitanguy published a report of 300 abdominal
lipectomies [10], followed by Regnault, who published the
W technique for abdominoplasty in 1975 [11]. In 1973,
Grazer was one of the first authors to describe the so-called
bikini-line incision [12], and in 1967 Callia described a low
incision that extended below the inguinal crease. This also
appears to be the first report of aponeurotic suturing.
From the 1970s on, all studies demonstrated that the most
convenient incision in patients undergoing abdominoplasty
was the low transverse incision.
Although aponeurotic suturing in the midline was noted to
be able to reduce anterior projection of the abdominal wall, it
did little to reduce the diameter of the waist. Liposuction,
invented by Illouz in 1980, radically improved the concept of
body sculpturing, and presented the opportunity to develop
the modern technique of abdominoplasty [13].
In 1984, Psillakis first suggested suture plication of the
external oblique musculature after raising it in a belt-like fash-
315
316 G. Di Benedetto et al.

a b

Fig. 1 (a) Demars and Marx, 1890. (b) Kelly’s technique, 1899. (c) Beck’s technique with preservation of the umbilicus, 1917
History of Aesthetic Surgery of the Trunk and the Extremities 317

a b

Fig. 2 (a) Frist’s technique, with tunnelization and repositioning of the umbilicus, 1921. (b) The French-bikini like incision. (c) Callia’s transverse-
inguinal-pubic incision, 1962.
318
ion [14]. In this way, he was able to dramatically reduce the
diameter of the waist. He also added refinements such as cos-
tal margin excisions in patients with a projecting upper abdo-
men. The concept of mini-abdominoplasty was introduced by
Hakme in 1985, combining large liposuction of the entire
abdomen with minimal elliptic resection of the sovrapubic
skin without dislocating the umbilicus: this is the first reported
association of liposuction with abdominoplasty [15].
Following this advance, many authors published different
types of mixed techniques, and in 1991 Matarasso expanded
the use of abdominal contour surgery to encompass a classifi-
cation based on variations in patient anatomy, from liposuc-
tion alone to limited abdominoplasty and full abdominoplastic
surgery [16]. Since then the use of pre-liposuction in the
abdominoplastic procedures has become very common.
In 1995, Lockwood described the so-called high lateral
tension abdominoplasty, whose key features include limited
direct undermining, increased lateral skin resection with
high tension wound closure along lateral limbs, and two-
layer superficial fascial system (SFS) repair.
When the Saint Tropez bikini (with a very low waistline)
was fashionable, the abdominoplasty incision was nearly hori-
zontal so as to achieve concealment under such a garment.
When the French-line bikini (with a very high leg cut) was
popular, the abdominoplasty incision had to be converted from
a nearly horizontal line to an incision line that accompanied the
inguinal fold. In 1997, Gonzalez and Guerrerosantos described
a particular technique called deep torso-abdominoplasty
whereby the abdominal incision was positioned higher to keep
it concealed under this new style of bathing suit [17] (Fig. 2b).
Since the turn of the century, bikinis with very low waist-
lines have become more popular again. Therefore, proper
adjustments in techniques are necessary to achieve a tailor-
made abdominoplasty. A sensible technical innovation was
introduced in 2001 by Saldanha’s group. Following the work
published by Avelar in 2000 [18], he developed a particular
combination of full liposuction and abdominoplasty with a
selective undermining, saving the abdominal perforating
blood vessels in the middle line and around the umbilicus.
Saldanha showed that the perforator vessels of the abdom-
inal panniculus, after abdominoplasty, work as multiple pedi-
cles to provide normal vascularization to the remaining
panniculus. This so-called technique of “vessel preservation”
is very important in avoiding ischemic complications of the
lower abdomen and providing good wound healing [19].
In summary, we may consider three main types of abdomi-
noplasty procedure, depending on the position of the incision,
with and without an associated liposculpture procedure:
1. Transverse-Inguinal-Pubic: this is the most common pro-
cedure, which provides a very low incision (Fig. 2c).
2. High Transverse: this is used for localized adiposity,
placed especially in the mesogastric region and often
associated with general surgery (Fig. 3a).
G. Di Benedetto et al.
3. Vertical or Mixed Transverse-Vertical: used only in
selected cases of bariatric surgery (Fig. 3b, c).
Less invasive procedures have been developed to meet the
requests and needs of patients. Nowadays, regardless of the
kind of technique used, the importance of an excellent body
profile and a perfect scar is the goal that every surgeon aims
for. In 2007 Forlini and Manjarrez described a simple trick to
obtain an optimal distribution of the skin and tension of the
limb, avoiding complications such as irregular scars and
dog-ears in these kind of procedures [20]. Silicone-based
medications and biological glue for sutures have been devel-
oped to further improve aesthetic results.
2 Brachioplasty
Reduction of excess fat and excess skin in the upper extrem-
ity is a concern of many women. On inquiry, the idea of a
permanent visible scar proves to be a deterrent to undergoing
surgery to correct the condition. However, when the defor-
mity is obvious enough and scarring is acceptable, a brachio-
plasty is an excellent surgical option. It is simple, easily
performed under local anesthesia, requires minimal or no
undermining, and rarely produces complications. Fat depos-
its lying between the breast and the shoulder, although rarely
mentioned, may be very unaesthetic and deserve special
attention. Their correction is also fairly satisfactory.
Brachial dermolipectomy is an efficient method of treat-
ment for lipodystrophy of the upper extremity resulting from
weight loss or aging. The excessive skin and fat that hangs
during abduction of the arm, which contributes to the con-
tour deformity, is excised. Unfortunately, this frequently
results in unsightly scars and contour deformity [21].
Previous operations for arm reduction were described for
adiposity rather than excess skin [22–24]. In general, the
procedure consisted of a simple fusiform excision of skin
and fat on the medial surface of the arm (Fig. 4a), leaving a
straight-line scar and producing redundancies at one or both
ends. This procedure was based on a misconception of the
dynamics of the condition. It is extremely rare that maximum
excess tissue lies at the midportion of the arm, yet the classi-
cal fusiform excision removes more tissue at the midportion
than at the extremities.
Pitanguy [25] (Fig. 4b) advocated his technique mostly
for patients after significant weight loss. Several modifica-
tions have been suggested to reduce postoperative complica-
tions and produce better results [22, 27].
In 1979, Juri et al. [26] published a flap reduction with T
closure, which brings about an improvement on the
upper-third reduction, but not above the elbow (Fig. 4c). The
use of a straight axillary line with a large T closure may give
some axillary retraction. On observation of numerous
patients, it is obvious that excess soft tissue is most
History of Aesthetic Surgery of the Trunk and the Extremities
a b
Fig. 3 (a) Thorek’s mesogastric excision, 1942. (b) Vertical excision as used by Correa-Itturaspe, 1952–1961. (c) Castaňares’ mixed technique
pronounced in the upper third of the arm rather than the mid-
dle third. In addition, there may be many unaesthetic folds in
the lower third above the elbow. Borges [27] used a long
W-plasty to produce a better, less retracting scar.
3 Thigh Lift
Localized and generalized accumulations of lower extremity
fat have tested the skills of plastic surgeons for decades.
Patients with localized fat accumulations often desire
removal for aesthetic reasons, whereas patients with large,
especially circumferential, accumulations desire removal for
both functional and aesthetic reasons. The recognition by
319
c
Kelly [28] of the possibility of direct excision of excess skin
and fat on the abdomen led to direct excision of localized fat
on the lower extremities as well.
The first report on aesthetic surgery of the limbs appeared
in 1946, by Posse [29]. Since then many techniques have
been proposed for correction of gluteal and thigh deformi-
ties. Early attempts consisted of vertical incisions on the lat-
eral and medial side of the thighs, combined in some cases
with horizontal incisions, but were followed by less than sat-
isfactory outcomes.
In 1957, Lewis described the circumferential excision of
thigh skin and fat with a vertical closure [30] (Fig. 5a).
Much later, in 1971, Farina performed direct lateral exci-
sion which, while improving the contour of the lateral thigh,
320 G. Di Benedetto et al.

a b

Fig. 4 (a) The fusiform excision after Baroudi, 1975. (b) The Pitanguy elliptic axillary excision, 1975. (c) Arm reduction with “T” closure, Juri, 1979
History of Aesthetic Surgery of the Trunk and the Extremities 321

a b

Fig. 5 (a) The circumferential excision of thigh skin and fat with a vertical closure, Lewis, 1957. (b) The thigh lift incision hidden within the
bathing-suit line, Pitanguy, 1971

produced huge, highly visible scars [31], and Pitanguy was
the first to describe a thigh-lift incision that was hidden
within the bathing-suit line [32] (Fig. 5b). This resection also
was the first to address inner and outer thigh skin and fat
excess and to correct buttock ptosis.
Abandoning the vertical incision component of the thigh-
plasty, Schultz and Feinberg [33] described the medial thigh
lift with excision of an ellipse of skin beginning below the
inguinal ligament in the genitofemoral crease and ending at
the gluteal crease. Their procedure was carried out in the
lithotomy position, using a two-layer closure. They did not
combine this procedure with abdominoplasty or posterior
thighplasty for fear of compromise of the venous and lym-
phatic return and subsequent healing problems. Whether
because of their initial low incision beneath the inguinal
crease or the difficulty in assessing the limits of tissue resec-
tion in the lithotomy position, the postoperative results dem-
onstrated inferior migration of the scars along with some
322
pubic hair migration. This problem of scar migration and
labial flattening or “splaying” was described in the book by
Grazer and Klingbeil, Body Image, a Surgical Perspective
[34]. Grazer’s incision lay slightly inside the inguinal crease
and more medial to the gluteal crease. Resection was carried
out in the frog-leg, not lithotomy, position [34]. Contiguous
procedures such as abdominoplasty were carried out by him,
and the incisions remained within the bikini line. No dermal
suspension was used and resection was conservative. Other
authors, including Agris [35], have utilized dermal suspen-
sion to achieve fixation of the elevated thigh tissues to the
fascia in an effort to prevent labial migration of the scars.
Teimourian and Adham [36] described periosteal dermal sus-
pension of the advanced thigh to achieve a more permanent
lift and correction of thigh ptosis. The conservative approach
with an incision above the inguinal crease was stressed by
Renault and Daniel [37]. The lithotomy position was not used
by these surgeons because of landmark distortion, and the
inability to access the appropriate resection and perform a
two-layer closure. Ashton [38] suggested a three-layer clo-
sure approximating the fascia lata of the lower flap to the fas-
cia of the inguinal ligament. More recently, Isaacs [39] and
Regnault and Daniel [40] showed several examples of unsat-
isfactory lower migrated scars from the inner thighplasty, and
indicated some disillusionment with the procedure. The com-
plication of perineal tightness was corrected by Regnault,
with the patients receiving a “good functional” result by using
the double Z-plasty technique to relieve the tight perineum.
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1. Demars MM (1890) Marx: surgical treatment of obesity. Prog Med
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2. Kelly H (1899) Report of gynaecological cases. Bull Johns Hopkins
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after classic techniques, prevention, and treatment. Clin Plast Surg
11(3):505–516
 Aesthetic Abdominoplasty
Carlo D’Aniello and Giuseppe Nisi
1 Introduction
The abdominal region plays a key role in establishing a
harmonious body shape. The assumption of the upright
position and the fact that it hosts within itself the “miracle”
of a new life puts it in a unique situation of visibility and
centrality, and makes it take on, although with different
facades sometimes opposed, high social, cultural, and even
religious importance. The close mixture of rigid cultural,
social, and religious canons has, over the centuries and until
the second half of the twentieth century, significantly influ-
enced the aesthetic vision of the abdominal region as it was
imagined, conceived, and represented. From the prehistoric
Venus “steatopygia” to the Baroque “Three Graces” by
Rubens through the medieval “Magdalene” by Gentile da
Fabriano, we observe an explosion of forms of the abdomen
that appear stout and prominent, a symbol of social prosper-
ity and auspicious of fertility.
We had to wait for the “cultural revolution” of the 1950s,
with the rise of mass media, women’s rights, and the birth of
the “cult of image,” for a radical change in the concept of
beauty and to witness the birth of a new aesthetic perception
of body shape, with a sort of precursor of the “globalization
of beauty,” free from religious, cultural, and social influ-
ences. Even the abdomen is affected by these radical changes,
and while maintaining its distinctive “centrality,” it “reveals”
itself, free of clothing, after for centuries having been hidden
from the eyes, and its roundness, a legacy of the old beliefs:
the dawn of the era of bikinis and very short T-shirts, mini-
skirts, and low-waist pants. The abdomen and its only point
of reference, the navel, end up being the key to a harmonious
body and are finally free to express their aesthetic potential
and their sexual power. At the same time, the desire for a flat,
sculpted, aesthetically attractive abdominal region increases
C. D’Aniello, MD (*) • G. Nisi, MD
Unit of Plastic Surgery, Dipartimento di Chirurgia,
University of Siena, Siena, Italy
e-mail: daniello@unisi.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_24
exponentially and begs for a correction of various
imperfections. Surgery, at least initially, fails to give ade-
quate answers. The first attempts are represented by selective
dermolipectomies, limited by the presence of the navel, with
poor cosmetic results and visible or not easily concealable
scars. The introduction into clinical practice of new surgical
techniques in the mid-1950s inaugurated the modern era of
abdominoplasty. The union of the dermolipectomy of the
lower abdominal region, transposition of the umbilical scar,
and the plasticity of the muscular wall of the abdomen
through incisions placed in areas where the scars are easily
hidden by clothing permit restoration or creation “ex novo”
of a profile of the region that is aesthetically pleasing.
Furthermore, the development over the years of the surgical
technique and the use of liposuction as an ancillary method
have offered, through a global morphovolumetric remodel-
ing, optimal solutions for the most varied inestetisms of the
abdominal region, making abdominoplasty one of the most
performed surgeries in the world.
2 History of Abdominoplasty
The first attempted cosmetic surgery of the abdomen as
reported in the scientific literature dates back to the late nine-
teenth century (1899), by Kelly [1–3], who made a series of
lipectomies through an elliptical abdominal incision passing
through the navel and extending from one side to another.
After Kelly, in the first decades of the twentieth century, sev-
eral authors (Morestin, Weinhold, Desjardin, Babcock, Jolly,
Thorek, Galtier) [4] codified techniques that differed in the
placement and type of the skin incision (Figs. 1, 2 and 3),
La Trenta describes Babcock’s [5] technique that combined
an elliptical vertical incision with detachment of the superfi-
cial layers from the muscular-aponeurotic layer of the
abdominal wall (Fig. 4). While presenting differences, these
techniques shared the common limitation of leaving serious
and difficult-to-conceal scarring sequelae. This limitation,
however, considering the strict morals of the time, which
323
324 C. D’Aniello and G. Nisi

Fig. 1 Dermolipectomy sec. Kelly [1] Fig. 3 Dermolipectomy sec. Galtier (1955)

Fig. 2 Dermolipectomy sec. Weinhold (1909) Fig. 4 Dermolipectomy sec. Babcock (1916)
Aesthetic Abdominoplasty
Fig. 5 Skin incision sec. Callia
judged as highly regrettable even showing the ankles, was
not considered a problem. With the radical change of the cus-
toms and dress of the 1950s and the introduction of more
showy clothing (including showing the adomen) in everyday
life, the scarring sequelae became an insurmountable prob-
lem. The abdomen should be aesthetically appealing, and the
only visible scar should be the navel. There was a progres-
sive abandonment of the “old” surgical techniques and
descriptions of new ones, launching the era of “modern
abdominoplasty.” The first to mark the beginning of the new
era was Vernon [6], who in 1957 described a surgical tech-
nique based on a large dermolipectomy, but this time per-
formed by a transverse incision. The incision was significantly
lower than all previously reported, adding an absolute nov-
elty through the transposition of the umbilical scar.
Since the technique proposed by Vernon, many authors in
subsequent years have contribute to codifying the basic prin-
ciples of abdominoplasty:
• Transverse skin incision placed at the upper end of the
pubic region
• Large detachment of the superficial tissues from the
abdominal muscular plane up to the sternal xiphoid pro-
cess and costal arch
• Abdominal wall plication with sutures of the rectus mus-
cles at the level of the linea alba
325
Fig. 6 Skin incision sec. Pitanguy
• Transposition of the umbilical scar
The various techniques (Figs. 5, 6, 7, and 8), while having
in common the surgical moments previously described,
differ—and not a little—in the form, pattern, and angle of the
suprapubic skin incision, especially in its lateral portions,
which are modified and modulated on the basis of the type of
clothing (skirts, pants, slips, and, mainly, bikini) with which
they will be hidden. Notwithstanding the central portion of
the incision, always positioned in the suprapubic region, are
its lateral extensions, which are changeable, according to the
fashion of the moment, and positioned, from one time to
another, below the inguinal fold (Callia), on the inguinal fold
(Pitanguy [7]), on the inguinal fold with a central incision
not rectilinear but arc-shaped (Regnault [8]), above the
inguinal fold with oblique lateral parts (Grazer [9, 10]), and
above the inguinal fold with “bicycle handlebar” shape
(Baroudi and Moraes [11]). The introduction in surgical
practice of liposuction in the early 1980s and its use as ancil-
lary method (Matarasso [12]) led to further developments of
technology, leading to the birth of the modern concept of
lipoabdominoplasty (Saldanha et al. [13], Uebel [14]). In
addition, a series of scientific studies on the vascular anat-
omy of the superficial layers of the abdominal region (Huger
[15], Tregaskiss [16]) and the publication of some details of
technique, aimed at reducing the “dead space” consequent to
326
Fig. 7 Skin incision sec. Grazer
the detachment (Baroudi and Ferreira [17], Pollock and
Pollock [18]) and a reduction in tension on the repositioned
abdominal flap (Lockwood [19], Le Louarn and Pascal [20]),
made it possible to maximize results and decrease
complications.
3 Surgical Anatomy of the Abdominal
Region
The abdominal region is delimited superiorly by the rib
arches and by the xiphoid process of the sternum, laterally by
two vertical lines, which starting from the anterior superior
iliac spines reach the costal arch, downwardly from the upper
edge of the pubic region, and by two oblique lines, which
starting from the lateral side reach the anterior superior iliac
spines. Before starting the description of the surgical tech-
nique that forms the basis of abdominoplasty, it is necessary
to proceed with an analysis of the anatomical structures that
make up the abdominal region (Fig. 5).
3.1 Skin
The skin of the abdominal region is thin and sliding on the
underlying layers. This surface must be carefully inspected
C. D’Aniello and G. Nisi
Fig. 8 Skin incision sec. Regnault
in the preoperative phase to assess the tone and elasticity, the
presence of scars from previous surgery, and the presence of
stretch marks, in addition to previous pregnancies and/or
important weight loss. A key component is represented by
the umbilical scar, which can occur in various forms (with
vertical, transverse, or round major axis) and with a depres-
sion variable with respect to the surrounding skin. The area
of the umbilical scar presents minor mobility compared with
the remaining abdominal skin, due to its greater adherence to
the underlying structures. It is located on the vertical line that
runs from the sternal xiphoid process to the symphysis pubis.
Of fundamental importance for its correct repositioning is
the preoperative measurement of the distance between its
lower edge and the upper edge of the pubic region. Equally
important is the palpation of the umbilical and periumbilical
(superior and inferior) area in order to detect the presence of
hernias.
3.2 Adipose Tissue
Representation of adipose tissue in terms of topographical
distribution and volume is extremely changeable, with
numerous variations based on gender, individual characteris-
tics, and nutritional status of the individual. The adipose tis-
sue of the abdominal region consists, especially in abdominal
Aesthetic Abdominoplasty
Fig. 9 Schematic representation of the main muscular structures of the
abdomen
inferior quadrants, of two layers, superficial and deep, ana-
tomically divided by a band of connective tissue under the
skin. This division becomes less clear heading toward
caudal-cranial, to disappear entirely in quadrants located
above the umbilical scar, in which adipose tissue is present in
a single layer (Fig. 9).
3.3 Muscles
Centrally the abdominal region is entirely occupied by the
rectus abdominis muscles, bilateral and symmetrical, that
extend from the upper rib (5th, 6th, 7th rib) and the sternal
xiphoid process to the pubic symphysis (Fig. 10). They are
joined together, in the midline, by a tendon raphe called the
linea alba, of about 2–3 mm thickness and a variable width,
which reaches its maximum in correspondence to the umbili-
cal scar. This area represents the “locus minoris resistetiae”
of the entire region to stresses arising from fluctuations in
intra-abdominal pressure. In particular, in female subjects,
physiological events, such as pregnancy, will induce a strain
with a consequent increase in width with widening of the
medial edges of the rectus muscles (diastasis), and will facil-
itate the onset of release of the abdominal viscera (hernia).
Laterally the aponeurotic muscle plane is constituted by the
overlap of more muscular structures, in particular the trans-
versus abdominis muscle, the internal oblique muscle, and
the external oblique muscle. These play a key role in the con-
tainment of the abdominal viscera and allow the bending and
twisting of the torso over the pelvis. Of particular interest for
abdominoplasty is the role of defining the minimum abdomi-
nal circumference performed mainly by the oblique muscles,
which must be carefully evaluated both preoperatively and
during surgery.
327
Fig. 10 Adipose tissue: superficial and deep compartments with a par-
ticular of superficialis fascia
3.4 Vascularization
Arterial vascularization of the abdominal region is provided
by the deep epigastric arteries, internal thoracic arteries, cir-
cumflex iliac arteries, and the intercostal and lumbar arteries.
The knowledge of vascularization of the superficial layers is
of great importance for surgery because it prevents postop-
erative ischemic complications. The superficial arterial circu-
lation of the abdomen is ensured by a network of subcutaneous
abdominal arteries, formed by the branches arising from the
circumflex iliac arteries and a series of perforating arteries
which, coming from the arterial deep circulation, cross the
muscular layer and lead to the subcutis and the abdominal
skin (Fig. 11). Based on studies conducted on the vascular-
ization of the superficial layers of the abdomen in relation to
surgical dissection (Huger [14]), the abdominal region can,
schematically, be divided into three zones (Fig. 12):
• Zone 1: The blood supply derived from branches of the
superficial epigastric artery and the continuation of the
branches of Zone 3. The area’s upper limit is the sternal
xiphoid process and the costal arch, the lower limit is a
diagonal line passing through the anterior superior iliac
328
Fig. 11 Schematic representation of the arterial supply of the abdomen
sec. Huger
Fig. 12 Periumbilical perforating vessel
spine, and the lateral limit is the lateral margin of the rec-
tus abdominis muscle.
• Zone 2: The blood supply derived from the branches of the
superficial and deep circumflex iliac arteries and branches
of the pudendal external artery. The superior limit is a
C. D’Aniello and G. Nisi
transverse line passing through the anterior superior iliac
spines, the lower limit is on the top of the pubic region, and
the inferior limit is represented by the lateral inguinal fold.
• Zone 3: The blood supply derived from posterolateral per-
forating branches from the intercostal, subcostal, and
lumbar vessels. The latter has as its upper limit the costal
arch, as lower limit a transverse line passing through the
anterior superior iliac spine, and as medial limit the lateral
margin of the rectus abdominis muscle.
The venous blood flow is ensured by superficial epigastric
veins, tributaries of the femoral vein, the thoracic and axil-
lary veins, and superficial venous branches of the last inter-
costal veins, the lumbar veins, and the external pudendal
vein. The large network of anastomoses between the superfi-
cial and deep circulation, the knowledge of abdominal vas-
cular areas, and their appreciation during surgery allows one
to perform large detachments in relative safety.
3.5 Lymphatic Network
The lymphatic vessels of the abdominal region are organized
in two independent systems, one draining the upper umbili-
cal portion, a tributary of the thoracic group of axillary
lymph nodes, and the other draining the subumbilical por-
tion, a tributary of the superficial inguinal lymph nodes. The
abdominoplasty determines an alteration in the lymphatic
system, especially at the groin and subumbilical level, which
can cause the onset of a postoperative seroma; however, tar-
geted maneuvers of the technique can decrease the occur-
rence of this complication [17, 18, 20].
3.6 Innervation
The abdominal wall is innervated by branches of iliohypo-
gastric and ilioinguinal nerves, and branches coming from
the intercostal nerves from T6 to T12.
4 Aesthetic Units of the Abdominal
Region
In addition to the classic division on an anatomical basis, the
abdominal region can be schematically divided into four dif-
ferent aesthetic units (Fig. 13), which are fundamental in
conferring the region its particular blend of form and vol-
umes, through alternating depressions and projections, con-
cavities, and convexities. For this reason it is essential for the
success of the surgical procedure to search for any imperfec-
tions during the preoperative evaluation of the various units
of the abdominal region, in order to implement a modulated
Aesthetic Abdominoplasty
Fig. 13 Schematic representation of the aesthetic units of abdominal
region
and focused surgical strategy, and thus be able to restore,
locally and globally, an acceptable morphovolumetric har-
mony. From the aesthetic point of view, one can identify the
following areas or units in the abdomen.
4.1 Upper Umbilical Area
This area is limited superiorly by the sternal xiphoid process
and the costal arch, laterally by the lateral margin of the rec-
tus abdominis muscles, and inferiorly by a line passing
through the inferior margin of the last ribs. This line, usually
located about 5 cm from the umbilical scar, represents the
minimum circumference of the abdominal region and is usu-
ally known by the term “waist.” The area is characterized by
an upper umbilical component of fat with little mobility on
the deep planes, and is organized to form a single layer and
the presence, in normal-weight subjects, of a slight depres-
sion on the skin surface relative to the surrounding planes, on
the median line corresponding with the linea alba.
4.2 Umbilical Area
This area occupies the center of the abdominal region. It is
limited superiorly by the line passing through the lower edge
of the last ribs, laterally by the lateral margin of the rectus
abdominis muscles, and inferiorly by a transverse line
passing through the anterior superior iliac spines. This line
represents the maximum circumference of the abdominal
region. This unit contains an important aesthetic element
329
represented by the umbilical scar, and for this reason the skin
and subcutaneous tissue in this area are characterized by an
almost entirely absent mobility on deep layers. In young and
slim women, the umbilicus resembles an oval-shaped
depression with a vertical major axis. It is located on the
median xipho-pubic line at a variable distance, between 10
and 15 cm, from the top edge of the pubic region. This
distance must be carefully measured and recorded, together
with the marking of xipho-pubis line, preoperatively and
intraoperatively, to perform a correct repositioning. It should
be noted that, as the navel is the only point of reference of the
entire abdominal region, any imperfection (congenital,
acquired, iatrogenic) will lead, inevitably, to a significant
alteration of the harmony not only of the aesthetic unit itself
but also the entire abdominal region.
4.3 Subumbilical Area
This area is limited superiorly by a transverse line passing
through the anterior superior iliac spines, inferiorly by the
upper limit of the pubic region and the inferior side of the
inguinal fold, and laterally by the lateral margin of the rectus
abdominis muscles. The area is characterized by a fatty com-
ponent, which is quite mobile on the deep structures and
organized into two layers, superficial and deep, separated by
a connecting septum called the fascia superficialis. This par-
ticular anatomical configuration makes it particularly
susceptible to variations in weight and both men and women,
and is prone to accumulation of excess adipose tissue.
Consequently, major aesthetic alterations of the entire
abdominal region are concentrated in this area.
4.4 Hips
Hips represent two areas attributed to a single aesthetic unit,
which laterally delimits the abdominal region. The superior
limit is the costal arch, the medial limit is the lateral margin
of rectus abdominis muscles, and the lower limit an oblique
line which, starting from the anterior-superior iliac spine,
reaches the junction point between the lateral and median
third of the inguinal fold. The fatty components are charac-
terized by a discrete mobility on deep planes and are orga-
nized in two layers, superficial and deep, divided by the
fascia superficialis that is continuous with that of the subum-
bilical region medially, while laterally it closely adheres to
the iliac crest. This area plays a key role, especially in
women, in the definition of an “ideal” body profile. In
women, in fact, the margin of the side draws a concavity
below the rib cage that suddenly changes in convexity at the
iliac crest, while medially it presents in the pararectal region
a small semilunar depression.
330 C. D’Aniello and G. Nisi

5 Selection and Evaluation

of the Patient

The main indication for abdominoplasty is represented by

the correction of excess skin and fat of the abdominal region
with or without skin and/or muscle wall laxity. In fact, there
are many variables that, individually or synchronously, form
the basis of changes in the aesthetic “ideal” of the abdominal
region:

• Age
• Pregnancies
• Changes in weight
• Changes in posture
• Past surgeries

These changes can affect the skin-fat component, the

Fig. 15 Distinct abdominal obesity: II degree
muscle-fascial component, or both at the same time, causing
an extreme clinical variability.
In our clinical practice we prefer to distinguish various
degrees of abdominal alteration in relation to the location
and extension, with or without associated musculofascial
laxity (Figs. 14, 15, 16, 17, and 18). In particular:

• Grade I: The panniculus is mainly distributed in quad-

rants below the umbilical scar and crosses the line of
pubic hair without covering the mons pubis, with absent
musculofascial laxity
– Grade Ia: with moderate musculofascial laxity
– Grade Ib: with significant musculofascial laxity
• Grade II: The panniculus is extended to cover the entire
pubic area with moderate musculofascial laxity
– Grade IIa: with significant musculofascial laxity.
• Grade III: The panniculus extends to cover the upper
thigh with significant musculofascial laxity
Fig. 16 Distinct abdominal obesity: III degree

Fig. 14 Distinct abdominal obesity: I degree Fig. 17 Distinct abdominal obesity: IV degree
Aesthetic Abdominoplasty
Fig. 18 Distinct abdominal obesity: V degree
• Grade IV: The panniculus extends to mid-thigh with
significant musculofascial laxity
• Grade V: The panniculus extends to the knee with
important musculofascial laxity
Of course, as regards the abdominoplasty with only
aesthetic purposes, the indication for surgery is reserved for
patients with distinct obesity of first and second degree.
In other cases, the value of the intervention is not only
aesthetic; the functional component also assumes clear
predominance.
As with all surgical procedures, before planning an
abdominoplasty it is necessary to make a careful analysis of
the patient’s general condition, in addition to cessation of
smoking at least for 2–3 weeks before surgery and stopping
any pharmacological treatment (nonsteroidal anti-
inflammatory drugs, oral contraceptives) from 10–14 days
before surgery.
The preoperative assessment of the abdominal area must
be performed with the patient in the upright position, identi-
fying and marking the landmarks useful for planning the
surgery. Particular attention should be paid to reporting any
scarring of the pelvic or abdominal area and the presence of
palpable swellings. In the orthostatic position, asymmetric
distribution of abdominal adipose tissue and changes in
the level of the umbilical scar are also evaluated. With the
patient in the supine position, the examiner palpates the
abdominal region with the abdomen relaxed (palpation
static) or by running sequential contractions of the abdomi-
nal muscles through coughing (dynamic palpation), which
allows better evaluation of the “possible” presence of mus-
cle diastasis and/or the presence of possible visceral
331
herniations. In addition to a careful physical examination of
the abdominal region, the clinician must perform a detailed
clinical history of the patient and appropriate laboratory
investigations (complete blood count, evaluation of liver and
kidney function, lipids, coagulation, and electrolytes).
Furthermore, it is important to submit the patient to X-ray
control of the lung parenchyma to exclude the presence of
pathology. In the case of significant diastasis of the abdomi-
nal musculature and/or the presence of hernia or incisional
hernia, it is very important to consider a preoperative study
of lung function, which can be greatly affected by the
increase in intra-abdominal pressure in the postoperative
period plication result of a possible hernioplasty, or of a
simple plication of the rectus abdominis muscles.
Furthermore, blood values are to be taken into consideration
in cases of patients with particularly low hemoglobin values
and/or to be subjected to important dermoadipose removals,
for which it is mandatory before surgery to organize a series
of blood samples for use in the postoperative period if a
blood transfusion is necessary.
Finally, in the case where the clinical examination high-
lights an important diastasis with diagnostic doubt about the
presence of abdominal hernia, it will be necessary to submit
the patient to imaging investigations (ECT, CT, or MRI). It is
also very important to detect the anthropometric data of the
patient, paying particular attention to body mass index which
can be, as reported in the literature, a reliable predictor of
surgical risk [21]. In our clinical experience the importance
of assessments has been underlined by the use of a special
checklist that allows all health practitioners involved to ver-
ify that the patient has completed all the necessary proce-
dures (clinical, laboratory, instrumental) throughout the
pre- and postoperative course.
6 Photographic Acquisition
The iconographic acquisition also plays a fundamental role
because with it, the surgical team can investigate and
re-evaluate the clinical situation and the operative strategy,
and obtain a precise analysis of the surgical outcome through
a detailed comparison of the images acquired pre-and post-
operatively. In addition, it plays an important role in medico-
legal terms. For these reasons it is necessary that the images
are acquired with a standardized method to obtain compara-
ble iconography before and after surgery, and to promptly
place and precisely highlight the anatomical region of the
surgical object, limiting to a minimum discrepancies and
artifacts in the acquisition. Specifically for the abdominal
region, the patient should be placed, completely naked and
barefoot, in the center and near the wall area chosen as
background (preferably dark colored so as to highlight the
profile body and minimize any glare light), and the surgeon
must be positioned at a distance of 1.5 m from the patient in
order to capture the image without using the zoom function.
332
Fig. 19 Frontal position
Fig. 20 Left side position
The patient’s positioning is fundamental to obtaining a com-
prehensive and accurate acquisition of the abdominal region
and, in particular:
• Frontal position: The patient is placed in front of the lens
with arms crossed behind the back (Fig. 19)
• Left and right side position: In this position the arms
should be folded behind the back and the patient laterally
rotated by 90° from the front (Fig. 20)
• Semi-lateral left and right position: In this position the
arms should be folded behind the back and the patient
laterally rotated by 45° from the front (Fig. 21)
C. D’Aniello and G. Nisi
Fig. 21 Semilateral left position
Fig. 22 Left lateral side diver position
• Left and right side position of the diver: In this position,
the patient is laterally rotated by 90° to the front position,
the arms should be stretched out in front, with legs straight
and trunk flexed at the pelvis (just about to dive) (Fig. 22).
7 Informed Consent
Proper administration of an informed consent to the patient
represents the “conditio sine qua non” for the execution of
the operation. It must be precise, complete, and comprehen-
sive, and has to be administered to the patient within an ade-
quate amount of time prior to surgery. It is necessary that it
contains the master data of the patient, the diagnosis, the
type of surgery proposed with its description, the type of
anesthetic procedure planned, all possible complications
Aesthetic Abdominoplasty 333

relating to the type of surgery and anesthesia proposed, and

the behavior that the patient must follow in the immediate
postoperative period. It is essential that the agreement has to
be drawn up with common terms, supported by the equiva-
lent strictly medical terminology in brackets, so as to be
readily understandable by the patient. It must also not be
merely delivered, but has to be read and discussed with the
patient, well in advance of surgery, to settle any doubt or
misunderstanding and to allow the patient to peacefully
decide whether or not to undergo the surgery procedure. It
must be signed by the patient or legal guardian, where
required, and countersigned by the doctor who administers
and (this is not strictly necessary but desirable) by at least
one witness.

8 Patient Preparation

Before entering the operating room the patient must be

properly prepared for surgery. In particular, the patient
should stop taking oral contraceptives and drugs contain-
ing acetylsalicylic acid, and smoking at least 2 weeks
before the scheduled date of surgery. The night before sur-
gery, the patient can safely eat dinner while in the morning
of the day of the operation he or she must remain on an
empty stomach to avoid the possibility of “ab ingestis”
pneumonia as a result of anesthetic and/or intensive care
procedures. For the same reason, on the morning of surgery
the patient must suspend drugs for oral intake and if sus-
pension is not possible or contraindicated, the administra-
tion will continue intravenously. In addition, the day before
the surgery the patient must be subjected to trichotomy of
the pubic region and must begin to wear compressive
stockings of the lower limbs and the subcutaneous admin-
istration, according to weight, of low molecular weight
heparin to minimize, together with the early mobilization
of the patient in the postoperative period, the possibility of
occurrence of deep vein thrombosis and/or pulmonary
embolism. The patient can take a cleaning bath the day
before surgery or before the execution of the preoperative
drawings, and must remove nail polish from hands and
feet, any gold jewelry (rings, necklaces), piercings, and
dental implants.
9 Preoperative Drawing
The preoperative drawing represents the first stage of sur-
gery, and is modulated and performed on the basis of clini-
cal evaluation and the choice of type of incision, which
can be exclusively transverse or transverse and vertical.
This last type of incision is to be reserved for patients with
pre-existing xipho-pubic scars from previous surgery or
when the patient has experienced a massive weight loss as
a result of diet therapy or bariatric surgery, which presents
significant dermo-adipose excess localized in lateral
Fig. 23 Preoperative drawing: schematic representation. A upper limit
of umbilical scar, B anterior superior iliac spine; C upper limit of pubic
region, D xipho-pubic line
quadrants, too difficult to tackle using a single transverse
incision. In most patients, then, and in case of an abdomi-
noplasty for purely aesthetic purposes, we opt for the sin-
gle transverse incision. In our clinical practice we prefer
to orient the choice of the skin incision according to
Grazer, which allows the removal of dermo-adipose excess
with a residual low scar and therefore is easily
concealable.
The preoperative design must be performed with the
patient in the upright position. Furthermore, one must iden-
tify and mark the following landmarks:
• Anterior-superior iliac spines to evaluate the lateral extent
of the transversal incision
• Superior limit of the umbilical scar
• Superior limit of the pubic region that will represent the
lower incision line
• It is also important to mark the line between the jugular
fossa of the sternum and the pubic symphysis. This is
needed to highlight any asymmetries of the dermo-
adipose component, and is essential for the correct repo-
sitioning of the abdominal flap and the umbilical scar. The
upper incision line can be identified, at the time of the
drawing, by running a series of pinch tests taking as a
fixed point the lower incision line, and will then be re-
evaluated, intraoperatively, at the time of removal of the
excess dermo-adipose portion (Figs. 23 and 24).
334
Fig. 24 Preoperative drawing on patient
Fig. 25 Disinfection and preparation of surgical field
10 Surgical Technique
The operation begins with the correct positioning of the
patient on the operating table (the position must permit to
safely lift the trunk, allowing the surgeon to be able to fully
evaluate the dermo-adipose removal and to promote the
synthesis of subcutaneous tissue and the skin with the least
possible tension), the placement of the catheter, the disinfec-
tion of the surgical area with iodine-povidone-based solu-
tion, and the preparation of the operating field with sterile
drapes (Fig. 25). At the time of induction, we perform the
antibiotic prophylaxis with intravenous infusion of
semi-synthetic penicillins or third-generation cephalosporins
(in case of allergy we proceed with the administration of
C. D’Aniello and G. Nisi
Fig. 26 Dissection of abdominal flap below superficialis fascia
Fig. 27 Dissection to the umbilical scar: intraoperative view
quinolones). The surgical procedure starts with the execu-
tion, following the preoperative drawing, of the skin incision
with the use of a paunchy lancet (No. 15, 10, or 24). The
surgeon proceeds with the incision of the subcutaneous adi-
pose tissue, by electric or ultrasound scalpel, until the super-
ficialis fascia is opened to expose the deep fat compartment.
At this point the surgeon begins the dissection of the abdomi-
nal flap that must follow the precise plan of detachment from
the area of incision, where it must be maintained immedi-
ately below the superficial fascia (Fig. 26), almost until the
umbilical area [20] (Fig. 27), to the muscle aponeurosis up to
the rib arch, and finally the sternal xiphoid process (Figs. 28
and 29). During the dissection, particular attention should be
paid to the isolation and the coagulation or ligation of perfo-
rating arteries, which come through the fascia to the subcuta-
neous tissue and skin of the abdominal region; if cut too
close to the muscle fascia these vessels may retract, making
it difficult to perform a correct hemostasis and requiring
opening of the same muscular fascia for their retrieval and
coagulation. In addition, particular attention should be paid
Aesthetic Abdominoplasty
Fig. 28 Schematic representation of abdominal dissection
Fig. 29 Complete abdominal flap dissection: intraoperative view
Fig. 30 Craniocaudal traction of the abdominal flap: the red line shows
the incision that divides the flap vertically
335
Fig. 31 Periumbilical shield-shape incision
to the umbilical scar, which must be carefully located so as
to avoid amputation during dissection. The abdominal flap is
pinched at its median end by two Kocher clamps, replaced on
the abdominal wall, pulled in a craniocaudal direction, and
divided in half by a vertical incision starting at the lower
portion of the future periumbilical incision (Fig. 30). This
allows the surgeon to proceed with accuracy and security at
the umbilical isolation.
At this point, the surgeon proceeds with the detachment
of the umbilical scar from the surrounding skin. In our clini-
cal practice this is done by lifting the upper and lower umbil-
ical apex with two Gillies hooks and performing a
periumbilical incision in a shield shape; this allows the neo
navel, once repositioned, to retrieve its natural shape with
greater vertical axis; subsequently the navel is isolated from
adipose tissue without, however, proceeding to excessive
skeletonization (Figs. 28, 31, and 32).
Once the dissection is performed, with particular atten-
tion to hemostasis, the surgeon proceeds to the next surgical
stage represented by the plication of the abdominal wall car-
ried out by plication of the rectus and oblique muscles. We
start by identifying and marking the medial margin of the
rectus abdominis muscles; this emphasizes the muscular
diastasis, if present, and identifies the edges of the muscle
plication to be performed (Figs. 33 and 34). The rectus
muscle plication is performed by placing separate stitches
336
Fig. 32 Isolation of umbilical scar from surrounding tissue
Fig. 33 Schematic representation of rectus muscles plication. a area of
oblique muscles plication, b dissection area limit, c portion of dermo-
adipose excess to be removed
along the length of the linea alba (Fig. 35). Below the
umbilical scar a greater amplitude of plication determines a
flattening of the suprapubic region. This is followed by plica-
tion, always with interrupted sutures, of the oblique muscles,
which is carried out by the last ribs up to the anterior superior
iliac spine (Figs. 36, 37 and 38). By modulating the ampli-
tude of the plication above the navel, the surgeon can achieve
a reduction of minimal abdominal circumference. The next
step is represented by the measurement of the distance
C. D’Aniello and G. Nisi
Fig. 34 Rectus muscles plication: intraoperative drawing
Fig. 35 Rectus muscles plication by interrupted sutures: intraoperative
view
between the transverse incision and the umbilical scar,
usually between 12 and 15 cm.
Hemostasis is re-checked, and the surgeon move on to the
next step, the transposition of the abdominal flap and the
repositioning of the umbilical scar. The abdominal flap is
repositioned on the abdominal wall, pulled in a craniocaudal
direction, and fixed by temporary sutures at the lower inci-
sion line, paying the utmost attention to the precise recon-
struction of the continuity of the xipho-pubic line marked at
the time of preoperative drawing (a good rule during surgery
is to resume drawing multiple times because this line repre-
sents a crucial landmark for proper repositioning of the flap
and the umbilicus). At this point we proceed to positioning
of the umbilical scar through execution, along the xipho-
Aesthetic Abdominoplasty
Fig. 36 Schematic representation of oblique muscles plication. a area
of oblique muscles plication, b dissection area limit, c portion of dermo-
adipose excess to be removed
Fig. 37 Oblique muscles plication: intraoperative drawing
pubic line, of the shield -shaped skin incision. The correct
position is detected on the basis of measurement previously
performed and controlled by placing, in correspondence with
the umbilicus, a Klemmer clamp, which is pulled upward
below the flap and identified with the index finger of the non-
dominant hand (Fig. 39). Once the shield-shaped incision is
made, the skin portion, gripped by an Ellis clamp and pulled
337
Fig. 38 Oblique muscles plication by interrupted sutures: intraopera-
tive view
Fig. 39 Measurement for positioning the umbilical incision on abdom-
inal flap transposed temporarily anchored at the lower incision
upward, is removed by the surgeon; this strictly controls the
hemostasis after removal. Moreover, always with the abdom-
inal flap and anchored in traction, the surgeon proceeds to
the evaluation of the dermo-adipose resection. In particular,
the vertical incision of the flap previously done and its sub-
sequent anchoring allow identification of two triangular
areas of excess tissue. Bilaterally the surgeon continues by
338
Fig. 40 Marking and removal of the excess dermo-adipose portion. Note the difference between the preoperative drawing and the one performed
intraoperatively
Fig. 41 Anchorage of the navel to the abdominal wall
pinching with a Kocher clamp the apex of the portion in
excess that is stretched in the horizontal plane in order to
evaluate it with precision and mark the cut line (Fig. 40a, b),
which is performed in a “flute mouthpiece” shape to facili-
tate an appropriate juxtaposition of the skin and subcutane-
ous tissue at the time of final suture. In this phase an important
technical skill is represented by the measurement of the two
incision lines (superior and inferior), which must be equal to
C. D’Aniello and G. Nisi
avoid skin redundancy (dog-ears) at the end of the skin
incision at the time of the repositioning of the flap and the
final suture. Once the incision for the repositioning of the
navel is made and the removal of the excess dermo-adipose
portion is performed, the temporary median sutures used to
replace the flap are removed and the surgeon proceeds to the
preparation of the umbilicus for its reimplantation. In our
opinion, at this point two technical skills are very important:
Aesthetic Abdominoplasty 339

Fig. 42 The navel is made to reappear and is anchored to the skin with
three suture stitches in non-absorbable monofilament

anchoring the navel to the abdominal wall with four cardinal

stitches (Fig. 41), and modest reduction of fat from the
Fig. 43 “Dead space” closure with multiple suture stitches
periumbilical portion of the flap; these operations allow to
confer to the navel its natural depression compared with the
rest of the abdominal region. The repositioning of the umbil-
ical scar continues with the placement of three sutures in
non-absorbable monofilament, at 3-o’clock, 6-o’clock and
9-o’clock, respectively, of the umbilical scar that will be
passed through the shield-shaped incision on the flap, and
that will bring out the navel and permit its anchorage to the
surrounding skin (Fig. 42).
The next surgical step is the closure of the “dead space,”
consequent to the detachment carried out to set up the
abdominal flap for transposition. This type of technique is of
considerable importance in order to:

• Minimize the possibility of occurrence of hematoma and

seroma
• Promote faster solidification between the subcutaneous
and the muscle-fascial plane
• Reduce the secretions with faster removal of drains Fig. 44 “Dead space” closure with fibrin glue
• Reduce the tension on the final scar

It can be performed by placing, in a craniocaudal direc-

tion and sequential order, of multiple suture stitches between
the lower portion of the flap and the abdominal wall [18]
(Fig. 43) or through the use of tissue adhesives based on
fibrin (Fig. 44). In the latter case it is useful to move the
drains (if already in place) and replace them at the end of the
application so as to avoid drain blockage through penetration
of the glue.
The use of drains, especially in surgical procedures with
extended detachments, is indicated to prevent the formation
of fluid collections as an indicator of a possible bleeding. In
our clinical practice we find it useful to use two suction
drains (round, with a diameter from 15F to 21F), one posi-
tioned in the upper and one in lower median umbilical por-
tion of the neocavity (Fig. 45) through two small incisions Fig. 45 Drain positioning
340
Fig. 46 Anchoring the deep fascia of the abdominal flap to the pubic
region to prevent rise of the medial portion of the transverse
incision
made in the pubic region (the regrowth of hair will help to
hide the residual scar). These are removed, typically after
48–52 h after surgery or when the daily secretion is less than
30 mL.
The final surgical act is the definitive repositioning of the
flap and the synthesis of the subcutaneous tissue and skin. In
this last phase, critical for the final aesthetic result, are three
technical expedients:
C. D’Aniello and G. Nisi
Fig. 47 Application of cyanoacrylate skin adhesive with pen
dispenser
• Anchoring the deep fascia of the pubic region to the deep
subcutaneous medial portions of the flap. This prevents a
rising transverse incision (Fig. 46).
• Suture in a double layer (deep and superficial) of the sub-
cutaneous tissue with a buried knot to prevent the suture
interfering with the scarring process.
• Intradermal suturing and application of cyanoacrylate
skin adhesive (Figs. 47 and 48) to avoid any other visible
scars (Fig. 49), to ensure a “barrier” with antimicrobial
effect and improve patient compliance [22, 23] (no suture
removal, reduction in postoperative medications, rapid
recovery to normal personal hygiene).
Once the skin suture is carried out, the surgeon treats the
abdominal region with elastic bandages that must be main-
tained until removal of the drains, at which point the elastic
bandage is replaced by an elasto-compressive tutor that the
patient must wear day and night for the next 30 days.
After returning from the operating room, the patient
must be guaranteed an adequate fluid replacement, ensured
antibiotic therapy, and administered analgesic and anti-
emetic therapy, if necessary. It is good practice to monitor
over the 2 days following surgery or until the time of dis-
charge, or to check the blood values with daily complete
blood counts.
At the time of discharge it also is essential to advise the
patient of the following recommendations in the postopera-
tive period:
• Total abstention from physical activity that can be
resumed, gradually, at least 5 weeks after surgery or after
a favorable opinion of the surgeon.
• Abstention from sexual activity for at least 3 weeks.
• Abstention from driving for at least 3 weeks.
Aesthetic Abdominoplasty
Fig. 48 Application of mesh with cyanoacrylate skin adhesive
Fig. 49 Aesthetic abdominoplasty: immediate postoperative appearance
11 Complications and Imperfections
Adverse events following abdominoplasty can be divided
into two main categories:
• Complications: This category includes all adverse events
that negatively affect the overall and innate health of the
patient. They are divided into immediate and delayed,
depending on the length of time after surgery of onset.
• Imperfections: These include all those surgical sequelae
that negatively affect the outcome of surgery from the
point of view of the aesthetic result.
341
Fig. 50 Flap ischemia and distal necrosis: wound diastasis after surgi-
cal debridement of necrotic tissue
• Complications: Hematoma is blood collection subsequent
to, in general, an inaccurate hemostasis during surgery. If
the hematoma has a significant volume and a rapid evolu-
tion, it can induce rapid anemia in the patient with the
need for urgent revision surgery to stop the bleeding, and
the need to perform blood transfusion therapy for the
rebalancing of blood values.
• Seroma is serous collection due to extensive damage to
the lymphatic network during dissection [20] and/or inad-
equate positioning and maintenance of compression ban-
daging in the immediate postoperative period. If in
significant quantities, it requires aspiration with a syringe
to reduce the increase of tension on the flap and the trans-
verse scar that may cause ischemia of the distal portions
of the abdominal flap and/or diastasis of the surgical
wound. Small collections can be identified and aspirated
with selective drainage under ultrasound guidance.
• Deep vein thrombosis, thrombophlebitis, pulmonary
embolism are due to inadequate antithrombotic prophy-
laxis, non-use of elastocompressive tutors in the lower
limbs, and/or a prolonged stay in bed by the patient who
has to be, with due caution, mobilized early. Pulmonary
embolism, a complication of rare occurrence, represents a
very serious adverse event and requires the immediate
transfer of the patient to an intensive care unit for
treatment.
• Ischemia and necrosis of the distal flap are related, in gen-
eral, to the median distal portion of the flap and may be
the consequence of a too extensive subcutaneous dissec-
tion and/or an excessive dermo-adipose removal, result-
ing in higher tension on the flap at the time of its
repositioning (Fig. 50).
• Umbilical scar necrosis may be the consequence of an
excessive skeletonization at the time of detachment of the
342
Fig. 51 Asymmetric scar
navel from the subcutaneous tissue and/or excessive trac-
tion due to an incorrect repositioning on the transposed
abdominal flap.
• Surgical site infection is relatively common even for the
“superficial” and “clean” surgical procedure represented
by abdominoplasty. To minimize the possibility of occur-
rence, it is necessary to establish appropriate antibiotic
therapy, observe asepsis at the time of surgery, and use
medical devices such as “active sutures” and topical skin
adhesives with bacteriostatic or bactericidal [22, 23]
power.
• Residual hypoesthesia/anesthesia of the transposed skin
flap: The necessary detachment from the muscle-
aponeurotic layer of the skin and subcutaneous tissue can
induce a momentary sensory neurapraxia of this anatomi-
cal area in the transposed abdominal flap. The persistence
of a hypoesthesia or anesthesia of the abdominal skin over
the physiological recovery times can be due to extensive
damage of the sensitive nerve fibers consequent to, with
high probability, an excessive widening of the upper and/
or side limits of the dissection.
• Visceral hernia recurrence is a frequent finding during
abdominoplasty, especially in parous female patients or in
C. D’Aniello and G. Nisi
Fig. 52 Insufficient skin-fat removal and dog-ears
those submitted to previous surgery in the abdominal
region. Despite the surgeon performing an adequate her-
nioplasty (even with the use of prosthetic devices) with a
plicature of the abdominal muscles, the patient must be
informed that such types of disease have a significantly
high rate of recurrence after surgery, especially long term.
• Imperfections: The imperfections are, in general, due to
an incorrect assessment and preoperative planning and/or
improper surgical execution, and are represented by:
• Insufficient removal of excess skin and fat (Fig. 52)
• Asymmetry in positioning and in the course of residual
transverse scar: the final scar may be too high and there-
fore be scarcely concealed, or have a different course
between one side and the other from the xipho-pubic cen-
ter line (Fig. 51)
• Asymmetric positioning of the umbilical scar: in the hori-
zontal plane with the navel repositioned too low or too
high, and in the vertical plane with the umbilical scar
repositioned not on the xipho-pubic line but on its right or
left side
• Presence of “dog-ears” are constituted by skin redun-
dancy of varying degree in correspondence with the ends
of the skin incision, and is the consequence of excessive
discrepancy in terms of length between the upper and
lower surgical incision and/or to inadequate apposition
and suture of surgical margins at the time of repositioning
of the abdominal flap (Fig. 52)
Aesthetic Abdominoplasty 343

12 Ancillary Techniques: Liposuction

Liposuction is the ancillary surgical technique most fre-

quently becoming associated with abdominoplasty.
Liposuction aims at the treatment of anatomical areas that
are difficult to treat using the classic procedure of abdomino-
plasty, and is performed to optimize results and obtain a
global morphovolumetric improvement. The anatomical
areas mostly submitted to liposuction during an abdomino-
plasty are generally the flanks and the pubic region; liposuc-
tion can also be carried out, albeit with due caution, at the
abdominal level [13] with the intent to reduce the thickness
of the adipose abdominal flap (Fig. 53). Liposuction can be
performed with traditional, pneumatic, or electric cannulas.
After preliminary infiltration of targeted areas, the lipoaspi-
ration can be performed in a “closed sky” way, before the
skin incision or once the abdominal flap is repositioned and
sutured, or in an “open sky” way, once the skin incision is
made (Fig. 54).

Fig. 54 Ancillary lipoaspiration: “closed sky” with traditional cannula

and “open sky” with cannula with pneumatic movement

Fig. 53 Schematic representation of target areas of ancillary

lipoaspiration
344 C. D’Aniello and G. Nisi

13 Check List

13.1 Check List Abdominal Surgery

Aesthetic Abdominoplasty 345

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ing. Aesthetic Plast Surg 27(4):322–327
14. Uebel CO (2009) Lipoabdominoplasty: revisiting the superior
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 Evolution of Lipoplasty Then,
Now, and the Future
Peter B. Fodor
This chapter outlines the chronology of the development of
lipoplasty in the United States and internationally over a
span of more than 30 years. Safe practices are promoted.
Technology on the horizon, with emphasis on minimally
invasive and noninvasive techniques, is also presented.
It has been more than 30 years since the introduction of
lipoplasty in the United States. During that time, it has
become the most frequently performed cosmetic operation,
with nearly 457,000 procedures in 2007. The number of lipo-
plasties has increased more than 158 % in the past 10 years
alone [1]. This chapter presents the development of the
approaches and technology, and reviews the important role
played by organized plastic surgery in furthering not only
interest and technical advances in lipoplasty but also the
awareness of patient safety issues. In this relatively brief
recap, it is inevitable that I may have inadvertently over-
looked the contributions of many gifted individuals, and I
apologize for any omissions.
1 The Initial Techniques of Fat Removal
The first known attempt to remove subcutaneous fat through
a small incision was carried out in 1921 in Paris, France, by
Charles Dujarrier, who operated on the calves of a Folies
Bergere dancer using a uterine curette. Unfortunately this
ultimately resulted in amputation of a leg. This was fol-
lowed, unsurprisingly, by a paucity of attempts to use this
methodology for subcutaneous fat removal over the next half
century.
Joseph Schrudde of Germany first reported on curetting
subcutaneous fat at the 1972 meeting of the International
Society of Aesthetic Plastic Surgery in Rio de Janeiro, Brazil.
He termed the procedure “lipexheresis,” which he stated “he
P.B. Fodor, MD
Private Practice, Santa Monica,
CA, USA
e-mail: pbfodor@centurysurgery.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_25
had performed occasionally since 1964.” In 1975 he pro-
vided a more detailed report on the procedure in Langenbeck’s
Archives of Surgery [2–6]. Blind undermining and the trau-
matic technique of using a sharp uterine curette frequently
resulted in prolonged drainage, lymphorrhea, hematoma,
and even skin necrosis.
The first surgeons to add suction for the purposes of fat
extraction, as opposed to just using curettage, were the
Italian father and son team of Arpad and George Fisher, who
presented their work in 1977 [7]. The tip of the instrument
was still sharp and, as a result, it severed not only fat but also
the surrounding structures. The postoperative course was
again marred by complications and side effects not unlike
those resulting from lipexheresis. The procedure was not
enthusiastically received.
The next advance worthy of mention was that of Ulrich
Kesselring [8–10]. Although he used sharp instrumentation
attached to suction, he was the first to recommend working
in the deep fat compartment just above the muscle fascia. His
results were superior to previous ones presented, in no small
measure due to his method of patient selection; he performed
the procedure only on young women with small amounts of
localized fat and elastic skin. Eventually, after a great deal of
lively debate with Yves Gerard Illouz at a variety of plastic
surgery meetings, Kesselring adopted Illouz’s technique.
Bahman Temourian was the first surgeon practicing in the
United States to make a significant contribution to the evolu-
tion of lipoplasty. In 1976, independent from the work of
European surgeons, he used a uterine curette to remove fat
during a secondary thigh lift. He first reported on his tech-
nique, with later modifications, in 1979 [11–15]. Temourian
recognized the importance of separate tunnels, as opposed to
a “windshield wiper” type of approach to fat removal. He
still, however, used sharp instruments and curettage. He
extended the procedure to many areas of the body, reporting
a 30 % complication rate, and eventually adopted a cannula
technique.
Illouz, mentioned earlier, was responsible for monumental
advances. He began in 1977, first reporting on his method in
347
348
Fig. 1 Illouz and U.S. pioneers
of lipoplasty: Illouz (on statue).
Left to right, Courtiss,
Teimourian, Mladick, Lewis,
Grazer, Hetter, Fredericks
1980 [16–18]. His most important contribution was the intro-
duction of blunt instrumentation that removed fat while respect-
ing the other structures between the undersurface of the dermis
and the subjacent muscle fascia. As a result, complications
were dramatically reduced, and the procedure became repro-
ducible in the hands of many other surgeons. The technique
was adaptable to a wide range of body regions and, for the first
time, its potential as a mainstay of aesthetic surgery became
apparent. He first presented the blunt lipoplasty technique,
which he called “lipolysis,” at the Shirakabe Clinic in Osaka,
Japan, in 1980. He also initially used the “wet” technique, infil-
trating 200–300 mL of infusate regardless of the expected vol-
ume of aspirate. Blood loss as measured by the “lipocrit,”
which is the hematocrit determination in the infranatant portion
of the decanted aspirate, was reduced to approximately 8–10 %.
By the time his milestone book, Body Sculpting by Lipoplasty,
was published in 1989, and as he became familiarized with the
SuperWet technique (the infusate-to-aspirate ratios of 1:1.5:1),
he adopted it and has used it since.
Additional comments on the evolution of the wetting
solutions are made later in this chapter. It is, however, appro-
priate to mention here that a significant contribution was
made in 1984 by Hetter, who added epinephrine to the “wet
technique.” This resulted in a further decrease of the aspirate
lipocrit values to 4–8 %. His book, The Theory and Practice
of Blunt Suction Lipectomy, published in 1984, remains to
this day a highly recommended text for students of lipoplasty
at any level [19, 20].
P.B. Fodor
Concurrently, Pierre Fournier and Francis Otteni of
France were popularizing the use of syringes as the suction
source in lipoplasty. They also favored noncutting-edge can-
nulae. They, however, unfortunately continued to advocate
the “dry technique” with no wetting solution preinjection. As
a result, with their method lipocrits hovered around 20–40 %
(Fig. 1).
2 Lipoplasty Begins and Gains
Popularity in the U.S.
In 1982, Illouz presented his technique for the first time in
the United States at the Annual Meeting of the American
Society of Plastic and Reconstructive Surgeons (ASPRS,
now the American Society of Plastic Surgeons, ASPS)
in Hawaii. This incited a tremendous amount of inter-
est among American plastic surgeons. Shortly thereafter,
ASPS President Mark Gorney had the foresight to cre-
ate the “Blue Ribbon Committee,” appointing Simon
Fredericks as Chair. The mission of this committee was to
visit Illouz and evaluate his work. On their return, the Blue
Ribbon Committee published a report with an extensive set
of recommendations.
The committee also developed a plan centered on gradual
introduction of the procedure to other US surgeons. It orga-
nized a number of teaching courses across the country which
did not, however, include live surgery demonstrations.
Evolution of Lipoplasty Then, Now, and the Future
Not long after the Blue Ribbon Committee’s visit to
Illouz, another group of surgeons, led by Gregory Hetter,
also visited the French surgeon at their own expense. This
group, soon after their return in 1982, founded the Lipolysis
Society, subsequently renamed the Lipoplasty Society of
North America (LSNA). The primary mission of this new
society was to teach the procedure to American surgeons. To
this end, about four “basic teaching courses,” which always
included live surgery, were annually presented by the LSNA
faculty. By the mid to late 1980s, the LSNA teaching sympo-
sia were in full swing. Within a 10-year period, more than 40
basic courses in lipoplasty were conducted. This resulted in
widespread familiarization and adoption of the operation.
Patient safety issues had a pivotal role in these teachings.
Illouz was a faculty member at most of these courses, and
Fournier was also invited to some of the sessions.
By 1992, it appeared that LSNA had fulfilled the mission
for which it was created, and logic dictated that it should be
absorbed by the American Society for Aesthetic Plastic
Surgery (ASAPS). The process of amalgamating LSNA into
ASAPS, however, took yet another 10 years. Lipoplasty by
this time was now being performed by a rapidly growing
number of surgeons around the world. Successful outcomes
were consistently reproducible and, when compared with
subcutaneous fat and skin excision procedures, the results of
lipoplasty seemed almost “magical.”
3 Wetting Solutions and Their Evolution
In addition to what has been previously mentioned about
wetting solutions concerning lipoplasty, safety is intimately
interwoven with their proper use, a subject of primary inter-
est to me for many years now [19–22].
By 1986, having had significant clinical experience with
the procedure, I became convinced that the most rational
fluid volume infusion-to-aspirate ratio was 1:1.5 mL of
infusate per mL of estimated aspirate, which I termed the
“superwet” technique. It was presented at many meetings
and eventually in the plastic surgery literature. With this
technique, the lipocrit values routinely were reduced to 1 %
[21–25].
Soon after, in 1987, the tumescent technique was intro-
duced by a California dermatologist, Jeffrey A. Klein. While
lipocrit determinations using this approach also hovered
around 1 % (not unlike the superwet technique), excessive
amounts of wetting solution containing local anesthetic, as
the sole anesthesia delivery system for the procedure, were
infused. When applied to major volume removals, xylocaine
toxicity [24] and fluid overload could readily occur, poten-
tially resulting in major complications. Some plastic sur-
geons, including a few with significant national reputation,
not only adopted the tumescent technique but arduously pro-
349
moted it, advocating its application to increasingly larger
volume removals. A “perfect storm” was in the making,
which predictably resulted in major complications and a
growing number of fatalities nationally [21, 22].
The advantages of the superwet technique in comparison
with the tumescent technique have been amply presented by
myself and others, and therefore are not discussed in any
greater depth here [25–27].
4 Ultrasound Technology Emerges
Beginning in 1987 and continuing to this day, there has been,
in my opinion, an ill-founded enthusiasm for mechanical
manipulation of adipocytes, resulting in their fragmentation
prior to aspiration. One of these widely popularized
approaches is the use of ultrasound energy to emulsify the
fat. In 1987, Nicolo Scuderi of Italy was the first to describe
ultrasound-assisted lipoplasty (UAL), after which a plethora
of publications endorsed the practice of UAL [23, 28–30].
My initial impression of UAL was confirmed by a clinical
study on my first 100 cases. The protocol was to compare
traditional suction-assisted lipoplasty (SAL) performed on
one side with the results of UAL applied to the contralateral
side during the same operation. In this way, patients served as
their own control. It was concluded that the benefits of UAL,
using the equipment available at that time, for the most part
did not justify the shortcomings associated with its use. It was
considered, however, that even at this early stage of the devel-
opment of UAL devices (first and second generation), the
technology offered some tangible benefits in treating body
regions with fibrous fat and in secondary lipoplasty [28–36].
In 1997 a meeting in St. Louis, hosted by Leroy Young,
was organized with the objective to facilitate the exchange of
ideas between leading biophysicists with interest in how
ultrasound energy affects adipocytes. In addition to American
board-certified plastic surgeons, industry representatives
were also asked to participate. After meeting William Cimino,
one of the PhD biophysicists present, I had the opportunity to
offer my clinical contributions to him as he was developing
Vibration Amplification of Sound Energy at Resonance
(VASER). This third-generation ultrasound lipoplasty device,
when compared with earlier devices, limited the power of
ultrasound energy delivery to levels which, while sufficient to
fragment adipocytes, were less harmful to surrounding lym-
phatics, blood vessels, and nerves [31–33]. Today there is
abundant independent clinical observation by a multitude of
surgeons that VASER-assisted lipoplasty (VAL) which the
company nowadays has termed “liposelection,” produces a
milder postoperative course and augments the tendency for
skin contracture. However, these observations are challeng-
ing to document objectively. At present there are several
350 P.B. Fodor

Table 1 Current technology I

Traditional lipoplasty Yes Demonstrated effectiveness, Avulsion ≥30 years; most
review significant scientific/ widely used
clinical body-contouring
technology
Power-assisted lipoplasty
MicroAire Yes Reduces surgeon effort Powered avulsion ≥10 years, initially
approx. 15
companies, currently
only 2
Lipomatic/Vibrolipo Effective, peer-revised
articles
Ultrasound
Lysonix Yes Effective in selected patients Emulsification/ablation ≥13 years, declining
market presence
Surgitron 3000 +/− Simultaneous aspiration
with traditional system
Sebbin Complications in proportion
with amount of energy used
Morwel Effective, peer-reviewed
articles
Medicamat
Mentor
SMEI

clinical studies in progress which, it is hoped, will provide
scientifically valid evidence for these outcomes.
External ultrasound-assisted lipoplasty (EUAL), com-
bined with subsequent aspiration of the fat, also has its pro-
ponents. EUAL may assist with disbursing wetting solutions
in the subcutaneous fat. Other proclaimed benefits have yet
to be proved (Table 1).
5 Additional Lipoplasty Advances
In the early 1980s a number of surgeons, some working inde-
pendently of each other, introduced the concept of superficial
lipoplasty [34, 35]. This advanced technique produced
impressive outcomes, at least in the short term and only in
the hands of experts. In the longer term, the results can dete-
riorate to a point where skin excisional body lifts become
necessary as a salvage procedure.
By the late 1980s, as demonstrated by the precipitous statis-
tical increase in the performance of the procedure, lipoplasty
had become the most popular aesthetic surgical procedure
worldwide. Simultaneously, applications of the operation were
extended to include challenging body areas such as lipoplasty
of the calves, ankles, arms, male and female breasts, back rolls,
and abdominal and pectoral etching [36–43].
Many surgeons worldwide contributed significantly to the
development of the procedure during the decade between
1980 and 1990. Excellent results could be generally
expected––depending, of course, on proper training and
experience and, to a lesser degree, on instrumentation.
Indeed, the majority of patients undergoing lipoplasty proce-
dures experienced uneventful and rapid recovery coupled
with satisfactory, if not outstanding, outcomes. On the other
hand, premature and overenthusiastic application of techni-
cal modifications of the basic procedure led to a significant
number of unsatisfactory outcomes. Insufficient training, a
cavalier attitude toward this seemingly simple procedure,
and limitations in technical ability and/or aesthetic judgment
all contributed to suboptimal results in some cases.
Even today, after significant physician education initia-
tives undertaken nationally and internationally, patients pre-
senting to my practice for a secondary operation far
outnumber those seeking primary lipoplasty. Unfortunately,
many of these patients did not select their surgeon wisely.
Approximately half are not good candidates for further sur-
gery. For the rest, depending on the deformity, the secondary
procedure will consist of additional lipoplasty either alone or
combined with autologous fat transfer, and some patients
will require skin resection procedures. Despite certain limi-
tations of secondary surgery, most of these patients are very
satisfied and grateful for the improvement obtained [44].
6 Power-Assisted Lipoplasty Emerges
The technology of power-assisted lipoplasty (PAL) [45–47]
has also been embraced by a large number of surgeons. This
mechanically propelled device lessens the effort expended
Evolution of Lipoplasty Then, Now, and the Future
Table 2 Current technology II
Ultrasound-assisted lipoplasty
VASER Yes Effective with lower energy (significantly reduced
complication rate), peer-reviewed articles
Gentle aspiration system
Silberg Yes Benefit not proven
Possible effect dispersion of wetting solution and
warning/massage
by the surgeon to extract fat, allowing him or her to concen-
trate more readily on sculpting (Table 2).
7 Additional Technologies
In 2000, yet another modality, lower level laser therapy
(LLLT), was introduced, with the claims that edema and pain
were reduced, wound healing and skin contracture aug-
mented, and larger volumes could be safely aspirated [48, 49].
In this technique, the subcutaneous fat is pretreated with
external laser energy before aspiration. Well-controlled clini-
cal studies have been unable to substantiate the claimed ben-
efits of LLLT [50, 51].
More recently, another laser-related body-sculpting meth-
odology has aggressively been promoted with catchy names
such as SmartLipo, CoolTouch, and a number of others that
utilize laser energy to emulsify the subcutaneous fat and alleg-
edly tighten the overlying skin. These all are combined with
suction during the same operative session. It is also claimed
that the laser energy seals blood vessels as it comes into contact
with them, leading to diminished blood loss. To my knowledge,
to date there have not been any publications in peer-reviewed
medical journals substantiating the purported benefits.
Conceptually the approach is identical to that examined by
Fodor et al. in a multicenter study published some 15 years ago
[52], in which we uniformly found that there was no benefit in
using this approach that in any way justified the expense, learn-
ing curve, and cumbersome nature of its application.
Improvements in the clinical application of lipoplasty
continue. These are fueled by excellent studies, such as those
by Kenkel et al., aimed at clarifying our understanding of the
physiologic events surrounding the procedure [53–55].
Similarly, the physics of the instrumentation used in lipo-
plasty have been extensively investigated [56].
8 Purported Invasive and Noninvasive
Technologies
There is a plethora of new innovations, as listed in the figures
and tables of this chapter, aimed at removing subcutaneous
fat for aesthetic purposes, some invasive, others minimally
351
Emulsification/fragmentation ≥10 years, with increasing
market presence
Thermal warning of fat layer ≥10 years, no significant
market presence
invasive, and some entirely nonsurgical. At the focal point of
most of these is the alteration of adipocyte integrity by a
multitude of energy-based (mechanical, thermal, laser, ultra-
sound) methods. This is offered either in combination with
aspiration (invasive techniques), or is based on the elimina-
tion of the altered adipocytes by the normal metabolic pro-
cesses of the body (noninvasive methods).
The media has been aggressive in endorsing “noninva-
sive” body-sculpting methods, or nonsurgical fat removal.
Widespread clinical application, not preceded by critical
research, has been a common occurrence. Such a modality,
with a questionable chance for satisfactory outcomes, is
mesotherapy, also presented by some as Lipodissolve, which
involves injection of the subcutaneous fat with a “cocktail”
of various chemicals, including but not limited to sodium
deoxycholate, phosphatidylcholine (PC), dl-α-tocopherol,
and benzyl alcohol. The true clinical value, especially in
light of the reported side effects and complications of this
methodology, remain highly questionable and also remain to
be asserted. To this end, ASAPS created a Mesotherapy
Committee in 2005 to review the existing literature and carry
out clinical studies.
The future should bring exciting new technologies for the
nonsurgical modification of subcutaneous fat. Of particular
interest is the external application of high-intensity focused
ultrasound (HIFU) for body sculpting. To date three compa-
nies, LipoSonix (Bothell, WA), Ultrashape (Yoqneam,
Israel), and Body Beam (Boulder, CO) are developing
devices with this technology [57, 58].
Because of personal involvement, I am far more familiar
with the work done at LipoSonix, a company that has con-
ducted a multitude of studies, first in a porcine model and
subsequently in humans, to evaluate the efficacy, precision
of control, and safety of this modality. In HIFU, focused
ultrasound energy is applied to the subcutaneous fat, and
subsequently the damaged adipocytes are metabolized and
excreted by the metabolic processes of the body. At the lev-
els of energy studied to date, no toxicity from the metabolic
by-products has been found. Although still in the early
phases, in these studies patients have experienced up to
7 cm of circumferential waist reduction following only a
single treatment using only conservative energy-level appli-
cations (Table 3).
352
Table 3 Emerging technology
Laser-assisted lipoplasty
SmartLipo Yes To date, insufficiently
proven
CoolLipo
ProLipo/Plus
LipoForm
LipoTherme
SlimLipo
LipoPulse
GoldLipo
SmoothLipo
AccuSculpt
RF-assisted lipoplasty
BodyTite Yes Unknown
Water-assisted lipoplasty
BodyJet Yes Unknown, encouraging
Liquid heat in motion No Unknown, quite encouraging Pressurized warm water within
9 Stem Cell Research
Another exciting development relates to stem cell research.
Subcutaneous fat may be the most ideal source for adult stem
cells. It is simple, safe, and inexpensive to procure and is
present in abundant quantities [59, 60]. Fat from lipoplasty is
the logical source for adult stem cells in comparison with
other tissues such as bone marrow, where the procurement is
painful and requires general or epidural anesthesia.
Furthermore, owing to the necessity of an ex vivo expansion
step before clinical use, bone marrow derived stem cells are
cumbersome and expensive. There is also a much smaller
yield of stem cells from bone marrow, where 100 mL on
average would contain only 1–10,000 stem cells compared
with approximately 1 million stem cells recoverable from the
same 100 ml of aspirate from subcutaneous fat.
Patients undergoing lipoplasty have the opportunity to
have stem cells isolated from their lipoaspirate and then
banked, with methods similar to those used to bank stem
cells from umbilical cord blood. This option has been offered
to patients in my practice for a number of years. The ages of
the first 10 patients who enrolled in this program ranged
from 39 to 71. All 10 have shown successful harvest and
isolation of mesenchymal origin adult stem cells. The aver-
age stem cell yield from these 10 patients was 1 million stem
cells per 100 mL of lipoaspirate. It has also been shown that
these processed lipoaspirate stem cells possess substantial
capacity for multilineage potential of differentiation in the
presence of lineage-specific induction factors. In vitro, these
cells have been differentiated, to date, into adipogenic, osteo-
P.B. Fodor
Laser photothermal ablation/ Approx. 2 years in
coagulation market ≥15 similar
devices, strong initial
media type
RF electrical heating of tissue New, not widely used
High-pressure water dissection New, not widely used
outside the cannula
Not applicable
cannula
genic, chondrogenic, neurogenic, and myogenic directions.
These processed lipoaspirate stem cells represent an excel-
lent choice for many tissue engineering strategies expected
to be developed in the not too distant future. There have been
ongoing studies in several centers on the application of adult
stem cells in repair of myocardium following acute myocar-
dial infarction, therapy for slow or nonhealing bone frac-
tures, and treatment for Parkinson’s disease. An exciting
potential application in plastic surgery is to improve the suc-
cess rate of autologous fat transfer, often associated with
unpredictable outcomes. Stem cells should be of great bene-
fit to patients needing fat transfer for the purposes of second-
ary lipoplasty in addition to buttock and breast
augmentation.
Conclusion
The development of subcutaneous fat removal through
lipoplasty, a rather minimally invasive approach, espe-
cially in comparison with excisional body surgery proce-
dures, has been an exciting and fulfilling one. The
procedure, when performed in properly selected patients
and by well-trained surgeons, has been hugely success-
ful. There is a multitude of even less invasive and nonin-
vasive methodologies constantly emerging. It remains
our duty, however, to critically evaluate these novel
approaches and to dissociate potentially deceptive mar-
keting while maintaining an open mind toward innova-
tions that are truly clinically valuable, currently proposed,
and certain to appear in the future (Figs. 2, 3, 4, 5, 6, 7,
8, and 9).
Evolution of Lipoplasty Then, Now, and the Future 353

Fig. 5 Hmmm...I guess you don’t need liposuction

Fig. 2 Dr. Fodor speaking on “super wet” technique

Fig. 3 Wet technique

Fig. 6 Adequate practical experience

Fig. 4 Ultrasonic liposuction

Fig. 7 What? Don’t you want to help me? Aren’t you one of the best?
354
Fig. 8 I would like to put my daughter’s stem cells in my checking
account. She may need them one day
Fig. 9 Mechanical liposuction
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 Tridimensional Liposculpture
Marco Gasparotti and Paolo Iannitelli
In a sculpture, shape is hidden in the stone, and it’s up to the artist to unveil it. Michelangelo
In liposculpture, shapes are hidden in the body of patients,
and it’s up to plastic surgeons to unveil them.
Liposuction is easy; liposculpture is difficult.
1 Introduction
1.1 Lipo: Not an Easy Procedure
Great surgeons and masters are humble. Mediocres are
arrogant.
After 33 years of experience in liposuction, I can certainly
state that lipo is one of the most complex operations in aes-
thetic surgery for three basic reasons:
• While surgery is carried out in the supine/prone position,
results are seeing in the standing position, and this has to
be considered. Also, the procedures frequently involve
both sides that are often asymmetric.
• It is a “closed” operation: it is based on the ability of the
surgeon to “feel” the result.
• Differently from abdominoplasties or mammoplasties,
corrections are very difficult. If too much is suctioned, it
will be very hard to correct later on.
After many years, I have now realized that liposculpture
must be perfect just after surgery, because the sentence “time
will set it up” here just doesn’t work. Given the increase of
surgeons doing liposculpture the rate of unhappy patients
following the procedure is rapidly growing. Hence, liposuc-
tion is now one of the most “dangerous” operations in aes-
thetic surgery for legal claims.
M. Gasparotti, MD (*)
Chirurgia Plastica, Università di Camerino, Camerino, Italy
e-mail: marcogasparotti@gmail.com
P. Iannitelli, MD
Chirurgia Generale, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_26
In my opinion liposuction requests maximal humbleness,
because often minimal mistakes may lead to important com-
plications. Liposculpture is an important surgical operation,
even if it is often considered minor by patients and by some
surgeons. The aim of patients is now not only a simple fat
removal, but a total body reshaping, a “remise en forme”
requiring fat removal from multiple areas.
With the increase in mean age, and the improvement in
living conditions, we now are asked to operate patients over
40 years, with problems of skin laxity and cellulite. Often,
anatomical problems are complicated by psychological
impairments such as depression and low self-esteem.
2 Indications to Liposculpture
The first liposuction operations based on fat suctioning were
performed by Schrudde, Fischer, Meyer, and Kesserling [1]
in the late 1970s. Truly, the first documented use of cannulas
to remove fat for aesthetic purposes was performed by
Dujarier, who used a gynecological curette to remove fat
from the legs of a famous dancer. Unfortunately, results were
dramatic because of vascular damage ultimately leading to
amputation. In 1964, Pitanguy reported an innovation for
trochanteric lipodystrophy, where scars were limited to areas
covered by underwear. In 1980, Schrudde used a curette con-
nected to an aspiration system. But the true pioneers and
fathers of liposuction are indeed Fournier and Illouz. They
first described in 1983 the use of a smooth cannula connected
to the aspiration machine. The term “liposculpture” was
introduced by Fournier who began in the 1980s fat aspiration
with syringes and subsequent lipofilling in order to have a
harmonic profile. Liposculpture has become a fashionable
term, but the original meaning has been forgotten. It is a true
body sculpture that allows to recreate convexities of lights
and shades typical of a harmonic human figure.
From the very beginning and particularly in the 1990s
because of authors like Gasparotti, Toledo, and Rohrich
[1–5], liposculpture has become a sophisticated technique
357
358
Fig. 1 A typical indication for
liposuction is represented by fat
deposits which do not disappear
after diet or physical exercise
and deform the silhouette
different from simple suction that allows the surgeon to
obtain total body reshaping. Unfortunately, the false simplic-
ity of the technique created during the years some confusion
especially in beginners, who thought that any type of skin
laxity or fat deposit could disappear with liposuction.
As any technique, liposuction has limits in indications.
For example, in treating the abdomen, it is always necessary
to consider the associated degree of skin laxity. This can ori-
ent the surgeon towards liposuction in patients with tight
skin and muscles or toward a mini/full abdominoplasty in
situations of muscle/skin laxity. The same concept is valid
for inner thigh treatment, orienting surgeons toward a lipo or
inner thigh lift, or in the aging neck, where sometimes pure
liposuction may even worsen the final result.
Liposculpture is indicated for fat deposits present
despite diet and exercise in patients age 45 years or younger.
Body contouring in these patients result in minimal skin
laxity (Fig. 1). In selected cases other techniques will be
associated.
Superficial tridimensional liposculpture has allowed the
extension of this technique to difficult areas (intergluteal and
infragluteal folds, trunk) and to patients over 45 years old
and with relaxed skin. The surgeon should understand, how-
ever, that the degree of skin retraction is maximal in the tro-
chanteric areas and on the lateral thorax and flanks, while it
is moderate on the inner thighs and arms, and on the abdomi-
nal wall, except when skin laxity is associated to multiple
stretch marks.
M. Gasparotti and P. Iannitelli
3 First Medical Examination
This is a very important moment. The patient should be seen
in a bright place, with a big mirror down to the ground.
The patient should undress and body asymmetries (hips,
flanks) should be pointed out. The patient should be aware of
postural defects, degree of skin laxity, and so on. Pictures
should be obtained in order to demonstrate what surgery can
truly achieve. Although incredible results concerning the
profile are possible with liposculpture, it will not be possible
to correct perfectly any asymmetry or small defect. Patients
often do not notice these points before surgery, they do after,
or their spouse or friend might. It is very important to evalu-
ate fat deposits and explain that hard ones may leave small
irregularities of the profile. On the contrary, when fat depos-
its are small, with skin laxity, deep and superficial liposuc-
tion might leave some irregularities.
Thickness of subcutaneous fat is measured with the pinch
test. Usually, the abdomen, flanks, and hips should have
more than 3 cm of thickness to get the real benefit from
liposuction. Other areas where pinch test is lower than 2 cm,
like heels, will rarely benefit from this procedure.
The degree of skin laxity is also very important in patient
selection. Tissue laxity on flanks, gluteal regions, and thighs is
evaluated by tractioning the skin over the iliac bones and look-
ing at modifications on the lateral thigh and gluteus. Usually
irregularities will disappear with this maneuver in most
patients. If in adjunct even the volume excess on the
Tridimensional Liposculpture
trochanteric region is reduced just with skin traction, then this
is probably due only to laxity than to fat excess.
Severe skin laxity is defined when the examiner is able to
advance skin more than 8 cm over the lateral thigh and flank
and more than 6 cm in the inner thigh. These patients should
be considered for a thigh lift or for a circumferential lift
according to Lockwood.
Abdominal skin laxity is evaluated by stretching the
abdominal skin in a vertical fashion, and should it be more
than 6 cm, a mini/full abdominoplasty is indicated, espe-
cially when epigastric laxity is present.
It is utmostly important to show the patient her pictures
also from the back and in the three-quarter view, to point out
asymmetries and defects. We prefer to correct pictures with
a marker instead of morphing as a default, to avoid unrealis-
tic expectations. Usually, we use morphing only when we
deal with responsible patients. Instead, when we deal with
obsessive or compulsive patients or people who ask too
many questions, we do think that morphing could be contra-
indicated and lead to legal problems.
The first medical examination should include a thorough
explanation on indications of surgery, on consequences
(scars, recovery), on limits, and, most importantly, on thera-
peutic alternatives. This will allow the patient to undergo
surgery confident and prepared to what she thinks is the best
solution for her problem. The medical examination will
include preoperative exams to be evaluated by the anesthetist
some days before surgery, in order to rule out if the patient is
on anticoagulants, hormones, and so on and to understand if
she will need some postoperative pain therapy. Before con-
cluding the examination, we evaluate the superficial and
deep venous system with color duplex scanning. The sur-
geon should explain all the possible therapeutic options, with
benefits, costs, and risks and alternatives for each procedure.
These factors, together with pain and different recovery
times, might influence the patient to undergo minor or major
procedures. The surgeon should conclude his consultation
having a firm approval for the operation. Having friends or
relatives of the patient at the consultation is a good idea; they
can support the patient in her decision and confirm the valid-
ity of our suggestions.
During the consultation, the patient will be informed
thoroughly about the length of her stay in the private hospi-
tal, the duration of surgery, and the possible pain, edema,
and ecchymosis during the postoperative period.
Complications should be pointed out, without frightening
the patient, but clearly and sincerely. It is also important to
let the patient understand the importance of an adequate
recovery time, because even a “light” operation under local
anesthesia needs time for pharmacological catabolism.
Surgical facilities should be appropriate, and an anesthetist
should be present. It is very risky to operate under unsafe
conditions.
359
Aesthetic surgery is not a cheap surgery, and should not
be. Reliability and safety are two utmost important issues.
At the end of the consultation, we usually give the patient
the informed consent that explains thoroughly the surgery,
pre-op and post-op treatments, and possible complications.
In this way the patient will have enough time to read and
understand the consent and take it back should she decide for
surgery. The very last step is done by the secretaries and
involves all the expenses for surgery: it should be precise and
mention also possible touch-ups.
4 Evaluation of the Volume
to Be Aspirated
Once the surgeon has established that the patient is a candi-
date for liposuction, determination of how much fat to be
removed will be made. The technical evolution in surgery
and instruments, together with the reduced blood losses, has
allowed massive suctions. This is defined as a suction over
5,000 cc per surgery. According to the international litera-
ture, there are no available data regarding the maximum vol-
ume to aspirate with safety. Obviously, the risk of
complications increases treating wider areas and greater vol-
umes. The body mass index (BMI) and the physiological
consequences of fat loss should be always considered, to
allow a proportional volume loss to physical conditions of
the patient. It is important to highlight the difference between
total fat removal and fluid aspiration, which is defined as the
combination between fat and fluids removed during liposuc-
tion. A well-experienced surgeon will be able to predict more
or less the volume to be aspirated: this will be extremely
important, even in the preoperatory phase, where one should
decide which will be the areas to treat. When dealing with
large areas, even with small volumes to be aspirated, caution
must be very high. Personally, I have never aspirated more
than 6,000 cc of pure fat, in a single session, even with an
overnight stay. I usually advice the overnight stay for more
than 2,500 cc to be aspirated.
5 Why a Tridimensional Liposculpture?
5.1 Philosophy of the 3D Liposculpture
The Webster dictionary defines sculpture as “the art of recre-
ating forms in 3D.” Recreating a harmonic profile is possible
because of the 3D approach to subcutaneous fat deposits
(Fig. 2). A thorough understanding of fat deposits and their
relationships with the underlying muscles is important in
order to have the best aesthetic results [6–9]. The concept of
liposculpture goes beyond traditional liposuction, i.e., fat
removal, but aims at creating a total harmonic body
360
Fig. 2 Achieving a nice body
contour is possible only with a
tridimensional approach
remodeling. The surgeon “sculptor” should create and cele-
brate the beauty of the human body. From this position, it
was easy for me to decide to become a plastic surgeon. When
I first observed a liposuction, over 30 years ago, this tech-
nique appeared to me as an “assault to holy areas.” It seemed
to me as an empiric technique, without well-defined guide-
lines, with rough instruments as those large cannulas of the
early 1980s. Then I understood, with time and experience,
that the goal of this operation shoudn’t have been only suc-
tioning of fat, but instead molding the body. Other points
came with time: why should I remove only the deep layer of
fat when the deformity usually includes also the superficial
fat layer? Why should I limit the use of cannulas to an aspira-
tion device, and not using it instead for sculpting the ideal
body? In other words, I often compare liposuction with rhi-
noplasty. As in rhinoplasty, we remove the bone and carti-
lage until we get to our ideal shape (Fig. 3), so in liposuction
we use cannulas to mold the body. In this way we can remove,
step by step, what our eyes see and our hands feel without
being scared by being too much superficial.
If compared to traditional liposuction, this innovative
method allows to achieve round shapes. In the superficial fat,
we have a plan which is set 1–2 cm under the skin, where the
cannula gets easily and smoothly. This is the correct plane of
superficial liposuction. But how deep is this plane? Honestly,
it is hard to establish, also because this is very patient depen-
dent (skin, fat thickness, age, etc.). The same happens in
M. Gasparotti and P. Iannitelli
other cosmetic operations such as face lift and so on, but for
sure, you can always get to a surgical layer where tissue ele-
vation is straightforward. On the other hand, when the sur-
geon gets too close to the dermis, scissors will encounter
some resistance, and this is where you can create defects and
permanent deformities. The same happens with 3D liposcu-
lpture. As we know, liposculpture involves molding skin,
dermis, and fat. Why should we limit our work to molding
fat, without considering its case, i.e., the skin? This is why
we started thinking of skin retraction as an allied force to
have optimal results. With massive tissue thinning, skin
retraction capacities are best utilized (Fig. 4). Thus, postop-
erative garments which support skin retraction (i.e.,
Tensoplast TM or Lipopanty TM) are very important, par-
ticularly when patients are not very young.
6 Clinical Series
Since January 1979 to January 2011, we have treated with
liposculpture 9,207 patients. The vast majority of tissue to be
removed was located in the outer thighs and flanks (87 %).
Most patients were treated contemporarily in several areas:
inner thighs (41 %), abdomen (18 %), knees (74 %), ankles
(36 %), and arms (1 %). Age varied from 16 to 72 years,
including young patients, middle-aged patients with relaxed
skin, and reoperations. On the basis of our extensive experi-
Tridimensional Liposculpture 361

Fig. 3 As in rhinoplasty, we remove bone and cartilage until we get to our ideal shape (Fig. 4), so in liposculpture we do not focus on the quantity
of fat removed, but on ideal concavities and convexities

ence, we do not feel limited by age and skin tightness. This

way of thinking evolves from Illouz’s technique and after from
Fournier and Otteni. It is then possible to have satisfactory
results both from an aesthetical and functional standpoint. We
now think that removal of fat limited to deep areas leads to a
very thick skin flap, which is prone to lower because of gravity
and edema. This explains why flap thinning leads to a dynamic
skin retraction, which means more support for thorough
remodeling. The more flaccid is the skin, the thinner should be
the flap after molding. As a matter of fact, a thin skin flap with
a compressive bandage allows a more controlled retraction, so
that operating middle-aged patients with suboptimal skin
quality is not impossible any more. Sometimes, lipofilling can
be extremely useful, acting as a biological glue to obtain fibro-
sis and a perfect adherence to the underlying layers. In conclu- Fig. 4 Plane of suction in superficial tridimensional liposculpture
362 M. Gasparotti and P. Iannitelli

sion, liposculpture is based on skin contraction and retraction

and on differences in healing between flaps of different thick-
ness. Similarly, the more flaccid is the skin, the more we
should thin the flap, so as to have the best skin retraction. This
is why, to our thinking, the skin flap should act as a case
enclosing the molded fat. With superficial liposculpture, the
skin is considered for the first time as an active and dynamic
structure, and not only as a passive element of surgery.

7 Anatomical and Technical

Considerations

The human body is formed by concave and convex layers.

There are no totally plane surfaces. The face, the breast, the
abdomen, the flanks, the hips and the thighs are an ensemble
of concave and convex shapes which interact continuously:
the tridimensional nature of our body should be respected, in
order to have natural results. Flanks should be slightly concave
Fig. 5 Improvement of the body profile after superficial liposculpture
in its upper parts and convex in the subgluteal region, so as to
descend gradually creating a right line at the level of the knees.
Even the inner thigh should not be flattened, but should be
slightly concave at its base, so as to continue gradually to cre-
ate a convex line at the middle third of the thigh. A small light
triangle should be visible at the radix of the thighs. The abdo-
men should not be totally flat, but slightly convex in its central
part and concave when descending laterally and inferiorly.
The basis of liposuction emphasizes three basic points:

• The use of concentric circles in order to draw the areas to

be treated
• A focus on the volume of fat to be removed
• Fat aspiration only in a deep plane

Tridimensional superficial liposculpture adds further

points:

• The surgical marking is based on a geometrical analysis

• A minor emphasis is on volumetric evaluation as a critical
surgical endpoint, emphasizing the importance of pro-
files. During rhinoplasty, a favorable profile of the nose is
not determined based on the cartilage and bone to be
removed, but only on post-op appearance.
• Fat should be removed in any layer, not only in the deep
one. Aspiration of deep fat allows a reduction of volume
but, at the same time, poses limits on body reshaping.
Traditional liposuction is based on deep fat removal. In
1989 we have modified this technique, including superfi-
cial fat removal in order to get benefit from tissue retrac-
tion even in older people. Now, the skin becomes the
“surgeon’s best friend” instead of being an enemy, as in
conventional liposuction. The thinner the skin-fat layer,
the more feedback from this anatomical structure.
Fig. 6 A 50-year-old patient with relaxed skin after tridimensional
liposculpture
Because of contraction, the skin becomes more tonic; the
classical aspect of cellulite improves, because many of
the fibrotic insertions connecting the dermis to the fat are
transected: the skin is now free to be moved easily and to
be repositioned. We usually reach the subdermal fat only
when we do need to thin maximally the flap, in patients
with flaccid skin. Superficial liposculpture never damages
the vascular plexus, and at least 3–4 mm of fat should be
left intact. The surgeon should feel as a “sculptor” when
performing a liposuction. Figure 5 shows the preoperative
(A) and postoperative (B) appearance of a patient after a
3D liposculpture. Figure 6 shows the preoperative (A) and
Tridimensional Liposculpture
postoperative (B) appearance of a patient with anelastic
skin after a 3D lipo. Instead, Fig. 7 shows a patient after
normal liposuction (A) and after 3D liposculpture (B).
Fig. 7 A 45-year-old patient who underwent four conventional lipo-
suctions by other surgeons. A 2-month postoperative result with a per-
fect skin redrapement after tridimensional superficial liposculpture
Fig. 8 (a) Typical trochanteric type. (b) Posterofemoral type. (c) Posteroinferior type (d). Gluteal fallout type
363
8 Patient Selection and Clinical
Evaluation
Tridimensional liposculpture appears as a less empiric tech-
nique, when compared to conventional liposuction. Apart
from patient selection criteria, the approach to the patient is
utmostly important, taking inspiration from artistical princi-
ples when compared to conventional criteria in classic lipo-
suction. In order to have a correct and precise setting of the
patient candidate, it is very important to know the classifica-
tion of fat deposits in 4 distinct groups:
• Type A – Mostly trochanteric (Fig. 8a)
• Type B – Posterior femoral (Fig. 8b)
• Type C – Posteroinferior (Fig. 8c)
• Type D – With typical gluteal fallout (Fig. 8d)
It will then be possible, on the basis of an appropriate set-
ting, to perform liposculpture following a logical sequence,
approaching any little anatomical asymmetry. Hence, every
different subtype requires an ad hoc treatment, according to
the aforementioned concepts, always trying to include in the
364
Fig. 9 (a) Correct surgical planning. (b) Highlighting possible asymmetries or skin irregularities. (c) Marking with the + or – signs of the areas to
be treated. (d) Obtaining desired results based on markings
preoperative drawing the entire deformity and then getting a
total harmonic profile. In conclusion, differently from con-
ventional liposuction, where the candidate was always a
young patient, liposculpture does not discriminate age nor
skin quality. A desirable result can be obtained even in
middle-aged and fair skin quality patients.
8.1 Preoperative Markings
8.1.1 Thighs and Flanks
The preoperative drawing should be meticulous and accu-
rate, typical of a sophisticated surgery, where details are a
basic point to reach the desired result. Markings should be
obtained in a standing position, with the legs well united.
One should proceed with the following sequence: right
thigh-right flank-left thigh-left flank-gluteal regions-torso-
inner thighs-abdomen-knees-heels-arms. The patient should
stand in front of a mirror:
M. Gasparotti and P. Iannitelli
1. A line should be driven to delimitate the entire area to
treat, in order to reach the far most point of the deformed
area, and the maximal projection point of such deformity
should be marked.
2. A + or – mark should be made where more or less fat
should be aspirated to achieve ideal curves. Surgery
should follow very precisely these markings, never tres-
passing the boundaries. The areas to treat are often differ-
ent on each side.
3. The areas to fill with lipofilling should be also marked, in
order to obtain an ideal curve.
4. One should evaluate, palpating or pinching the fat depos-
its to remove, the approximate amount of fat to aspirate
and write this data under the area to treat.
5. Any depression or dermic irregularity should also be
marked, so that the surgeon can recognize them and be
sure they are not amenable to technical errors (patients
should be well aware of these deformities before surgery!)
(Fig. 9).
Tridimensional Liposculpture
6. Evaluate how much fat should be removed and when suc-
tion should be discontinued with a simple maneuver:
pressing on the lateral femoral deformity toward the inner
side, to evaluate clearly the new desired shape, and then
marking a line just under our hand in this new position.
This plane will be the new level we want to get on the
lateral femoral profile. During surgery, we will discon-
tinue suction when we will reach this point. Any type of
deformity should be treated according to artistical con-
cepts, always trying to include the whole defect during
surgery and get to a total 3D harmonic shape.
8.2 Gasparotti G Point
One of the most important aspects of 3D superficial liposcu-
lpture is the G point modeling. The G point represents the
junction between the gluteus and the lateral thigh (Fig. 10).
The anatomical boundaries of this area are defined by the
cutaneous projection of the Roser-Nelaton line (laterally,
from the transition between the posterior and lateral part of
the thigh, and inferiorly the margin of the drawing). In the G
point, liposculpture helps to achieve a slight concavity. This
will enhance the gluteal roundness and increase the length of
the lateral portion of the thigh. The area of the G point cre-
ates a roundness after a superficial liposculpture, which
makes a new and more desirable curve.
Fig. 10 Anatomical landmarks
of the G point
365
8.3 Surgical Technique
The patient lies supine only when the abdomen is treated: the
frog position is preferred to treat the inner thigh and the knee,
whereas the supine position or the lateral one is better for the
heels. The patient should lie laterally when the flanks and the
trochanteric region should be treated, with a pillow between the
thighs, so that the area to be removed is highlighted. In the lat-
eral position, as a matter of fact, the defect to be corrected is not
modified from the underlying pressure from the lateral muscles
of the thigh. This will be instead flattened when the patient lies
in the supine/prone position. The lateral position also guaran-
tees a better vision of the surgical area, and less bleeding,
because of the alternate compression (Figs. 11 and 12).
Two longitudinal 3 mm-long incision are done with an 11
blade. The first one is carried out on the superior part of the
drawing, whereas the second one on the lower part, where
the fat pad begins to decrease. Under general anesthesia, the
area is infiltrated with 500 ml saline solution and 1 ml of
adrenaline, using a multiple hole-cannula that helps to have
a uniform diffusion of the anesthetic solution. Under local
anesthesia, when treating minor deformities, we add to the
solution 25 ml of lidocaine 1 % and 7 ml of sodium bicar-
bonate. Then, we apply some ice to the areas to be treated, in
order to achieve a better vasoconstriction. After 10–15 min,
which is enough to have a good ischemia of the area, we
begin surgery. We use 50 ml syringes, or Mercedes-type
366
Fig. 11 Gluteal rejuvenation
due (also) to the G point
Fig. 12 Maximal thinning of the flap after superficial liposculpture
cannulas 2, 3, and 4 mm, or cannulas connected with the
aspiration machine; sometimes we use 5 ml syringes with
2 mm cutting edge-cannulas, to do the touch-ups when treat-
ing hard consistency fat. These cannulas help us to work
properly, parallel to the skin. After having undermined the
intermediate and superficial layer of the area to treat with the
aid of a cannula, we aspirate fat in the tunnels created, using
a 4 mm cannula until a substantial reduction of the deformity
is obtained. Then, after conventional liposuction, we begin
with superficial liposuction. After the intermediate fat
removal, an improvement of the region is usually obtained.
Anyway, with few maneuvers, we can easily note, only in the
M. Gasparotti and P. Iannitelli
orthostatic position, that some residual fat remains. By press-
ing the fat down to simulate the gravity effect, the superficial
subdermic fat is visualized along the whole treated area.
Using a 3 mm cannula, some crisscross tunnels are made to
aspirate this residual fat very superficially. Touch-ups are
obtained with 2.5 mm cannulas for the treated and surround-
ing areas. In order to verify that harmonic curves are
obtained, we position the patient in an anti-Trendelenburg
position, to simulate the orthostatic position. When some
minor deformities are still present, we prefer to mold fat only
by hand, and not with cannulas. The thickness of the flap
should differ slightly in the treated areas, to get a harmonic
3D shape of curves and volumes. The residual adipose layer
is now very thin and lies on the intermediate adipose layer
previously treated. We stop when we get a harmonic profile
from the belt to the knees, with a concave flank, a convex
hip, and a well-defined round gluteus, a slight concavity in
the G area, and when we reach the previously marked area,
this is the ideal profile that we were thinking at during the
first consultation. The so-called banana deformity can be
corrected by a superficial liposuction: as a matter of fact, by
aspirating fat in a superficial layer, we can obtain an impor-
tant skin retraction, without removing the deep fat which
supports the gluteal region, in this way avoiding the gluteal
fallout (Fig. 13). Another trick that might help to evaluate
when we should discontinue suction is the “small cap maneu-
ver.” When we think we have reached the maximum aspira-
tion possible, we insert a small metallic cap between the
thighs of the patients who is, of course, lying in a lateral
Tridimensional Liposculpture
Fig. 13 Location of the subgluteal fat, also known as banana deformity
Fig. 14 A 62-year-old patient
with important banana
deformity and trochanteric
fat pads
position. The assistant lifts the thigh where we are working
with that cap, so as to flatten the muscles of the region. By
passing our previously wet left hand on the treated area, we
can check if the area is now smooth without any irregularity.
The treated area should be slightly concave in this position
and should become straight with the patient standing.
Another good evaluation of the profile is made with the
“eyeballing” of the patient at the level of the thigh. This
method will allow us to do some touch-ups for any minimal
asymmetry: every side should appear symmetric, although
different quantities of fat could be removed. A final pinch
test is important to establish symmetry (Fig. 14).
367
At the end of the operation, we insert an aspiration drain in
the lowest incision, in order to avoid ecchymosis and possible
permanent hyperpigmentations, and we irrigate the under-
mined area with 160 mg of gentamicin (diluted in 50 ml of
saline). While we are putting the elastic bandages on with
Tensoplast, we lift the skin according to Langer’s lines in order
to have a perfect flap repositioning. We use bandages basically
only for the trochanteric areas and some Reston for the other
areas, recommending a compressive garment at the end of sur-
gery for the remaining treated areas. For those patients who
underwent general anesthesia, a 12-h observation with drains
as an in-patient is recommended. Both Tensoplast and Reston
368
Fig. 15 The treated area is taped with Tensoplast and cotton bandages,
favoring the upward retraction of the flap according to Langer’s lines
are maintained for 4 days. After removal, the patient will wear
a more compressive garment for a month’s time, only during
daytime. The garment that we have designed has some elastic
reinforces to support (and not only to compress) the most criti-
cal areas. The contraction of flaps, lifted by Tensoplast and
garments, will determine a slight elevation and upward rota-
tion of the gluteus (Fig. 15). When also hells and knees are
treated, then the garment is worn night and day. We prefer to
stay deeper when treating the abdominal region, because irreg-
ularities are more frequent. If we need more retraction in some
flaccid abdomens, we undermine thoroughly the skin of the
flanks, of the suprapubic and inguinal areas. Even a minimal
liposuction of the suprapubic and inguinal region can deter-
mine a youthful effect in women over 40s.
8.3.1 Results
In our experience based on 9,207 cases of superficial lipos-
culpture, 98 % of our patients were very satisfied, and the
long-term results as to body remodeling were maintained
even in pregnancy (5 %) or in situations with increase/
decrease of body weight (37 %). In the remaining 2 % of
patients, we had the following complications:
• An increase in mycobacterial infection rate (defeated
after antibiotic therapy) probably caused by lipofilling
contamination.
• 20 minor asymmetries that were corrected 6 months later
under local anesthesia.
• 18 minor cutaneous irregularities, improved after
lipofilling.
• 6 cases of transient hyperpigmentations (6–12 months) of
the skin, before we started to use drains when removing
important amount of fat in fair skin patients.
• 2 cases of transient paresthesia (8 and 10 months).
M. Gasparotti and P. Iannitelli
• 4 cases of epigastric seroma, treated successfully after
several weekly aspirations. We never had any necrosis or
skin damage or permanent seroma.
8.3.2 Evaluation of Technical Details
If one remains in the correct layer that is under leaving no
less that 3–4 mm of vascular subdermal plexus, there is usu-
ally no mistake. There is a layer under the superficial fat
(0.5–1 cm under the skin) where cannulas penetrate easily.
This is the correct layer for superficial liposuction. If it is too
close to the dermis, the cannula will not penetrate so easily.
This is similar to what happens during facelifts. There’s a
layer where scissors proceed very easily, and we can feel
we’re too superficial when scissors can’t go forward without
a big effort. So, the trick is to prepare several tunnels very
close to the areolar layer of fat, close but not against the der-
mis, in order to leave a nice thinned flap. We never create
concavities, but always aspirate creating tunnels.
Liposculpture is not an operation for beginners and has a
long learning curve because it is more refined and difficult
when compared to conventional liposuction. Try to learn this
technique from the experts, and never underestimate this
operation. Although concepts are essential, it needs time to
be well done. So, it is better to be conservative in the begin-
ning, even if one thinks to be familiar with conventional lipo-
suction. It is reproducible following good basic artistic
principles and can give excellent results in experienced
hands. It is much more than a simple fat removal, bringing
liposuction towards a “shaping” dimension.
The concept of concavities and convexities, looking at the
body in 3D, determines further effects:
• Elongation of the lateral portion of the thigh, by trans-
forming the lateral part of the gluteus in a part of the
thigh.
• Elongation of the dorsum with augmented projection of
the gluteus: aspiration of the lower part of the dorsum and
sacrum reduces the length of gluteus, consequently aug-
menting dorsum extension and gluteus prominence.
• Upward retraction and rotation of the gluteus; the incision
point that we use, and the aspiration vectors consent the
upward lifting of the gluteus skin flap, lifting its postero-
lateral area.
The aspiration of the gluteal area just over and inside the
intergluteal fold produces an upward and inside rotation of
the skin, with a consequent change in the subgluteal angle
from more than 90° to less than 90°.
A circumferential thigh aspiration, when necessary, offers
a youthful appearance to the lower body. A further aspiration
(10–20 cc) of the inner thigh just lateral to labia majora cre-
ates the so-called light triangle, which gives harmony and
Tridimensional Liposculpture
Fig. 16 Note how simple
minimal liposuction (few
milliliters) at the radix of the
thighs, just laterally to the labia
majora, creates light in this area,
with a youthful effect. This is the
light triangle that I described
lightness to the gluteus as we already emphasized in previ-
ous papers [11] (Fig. 16).
Fat removal from the gluteus by vertical tunneling is
important in order to avoid the gluteal fallout on the poste-
rior thigh, with a reappearance of fat deposits and the banana
deformity. Furthermore, the interruption of the dermal liga-
ments between the lateral portion of the gluteus and the
upper part of the lateral portion of the thigh allows further
vertical skin retraction in this difficult area, now free to
move. In patients with very relaxed skin, the immediate post-
operative aspect will be the one of a slightly contracted skin,
which will definitely improve when the patient will ade-
quately move. In the last 15 years, the 3D superficial
technique has allowed us to reduce the number of abdomino-
plasties and thigh lifts, avoiding unsightly scars, with confi-
dence of the capacity of skin retraction after aggressive
thinning of flaps.
9 Liposuction of the Torso [10, 11]
9.1 Gynecomastia
In patients over 30 years old, gynecomastia often presents
with a mixed component (fat and glandular fibrosis), and this
369
might increase with age. This is why in these cases, liposuc-
tion should be done with great cautiousness; it can be fre-
quent, as a matter of fact, that cannulas cannot move easily
because of tissue consistency, and this might cause skin
irregularities. False gynecomastia should be treated surgi-
cally with liposuction, whereas surgical excision should be
reserved for true gynecomastias where excision of excess
glandular fibrotic tissue is necessary. The markings in the
breast area will extend laterally in the lateral thoracic region,
over the anterior axillary line, toward the posterior axillary
line, at the level of the axillary tail, which often associates
with fat deposits in this area. It is utmostly important to mark
the inframammary fold and the adherences of the skin enve-
lope, in order to disrupt these structures and free the skin for
an optimal redistribution after surgery (Fig. 17). When
approaching a true or mixed gynecomastia, where glandular
excision is necessary, the periareolar line of incision to
approach the gland should be marked. Typical access for
liposuction is achieved through an incision located posteri-
orly to the axillary pillar, another one in the inframammary
fold, in the lower border of the areola and, finally, at the
sterna junction. After infiltrating the area with local anes-
thetic (500 cc of saline, plus 25 cc of lidocaine, 1 mg of
adrenaline, and 7 cc of bicarbonate), we usually wait 15 min
for the vasoconstrictive effect. With the patient under local
370
Fig. 17 Note the preoperative
markings and the postoperative
result 1 month after surgery
anesthesia and sedation, or general anesthesia, liposuction is
then achieved with a 4 mm Mercedes cannula for the first
steps. A second step is achieved using a 3-mm cannula, for a
maximal thinning of the flap. The breast area is aspirated
aggressively until a very thin flap is obtained and has the
final look of a slight concave area. After surgery, a lymphatic
edema typically appears, but the surgeon should not avoid
aggressive suction, as postoperative folds or “whole” are
very rare in this area.
The more flaccid is the skin, the more should the surgeon
cross the margins of the area, with particular emphasis on
disruption of the inframammary fold in order to have a nice
postoperative redrapement. Often a lateral thoracic liposuc-
tion is associated, with the goal of eliminating those anti-
aesthetics subaxillary fat deposits. Obviously, thinning will
not be the same in every area, with maximum thinning in the
parasternal area, thicker in the upper quadrants towards the
clavicle, and thin again toward the axillary tail.
During the first postoperative days, edema is the rule;
occasionally, the edema may persist for 1 or 2 months, and
the patient should be informed.
We rarely use drains, unless we treat older patients with
extreme skin laxity; in these cases, a venular contraction
impairment with intima disruption might appear, so that
bleeding can be more noticeable.
A Reston or Tensoplast bandage is used for 4 days, after
which an elastic garment should be worn for 3 weeks day,
night and day.
M. Gasparotti and P. Iannitelli
10 Liposuction of the Arms [12]
Liposuction of the arms is not a difficult procedure and gives
good results for patients. We usually perform this operation
in the posterior and lateral region and more rarely in the
inner arm region. While there is no limitation in indications
for liposuction in the posterior and anteroposterior region,
the same is not true for the medial and inner parts. Here, for
pinch tests over 4–5 cm, particularly in patients over 45 years
old, we prefer to do it in association with an arm lift or a true
brachioplasty. We think that a small and hidden scar is pref-
erable to an excessive skin redundancy.
Markings are usually done with the patient in a standing
position and the arms along the body. In those cases where
a consistent adipose layer in the posterior arm is present,
the new plane should be marked pressing the area towards
the inside and then tracing a line under the hand (Figs. 18
and 19).
11 Liposuction of the Abdomen [13–15]
Although many authors emphasize the results obtained with
aggressive abdominal liposuctions, especially when skin lax-
ity with striae distensae are present, we do not agree with a
indiscriminate use of liposuction in these cases. Here,
although the result sometimes can be acceptable, avoiding
Tridimensional Liposculpture 371

Fig. 18 Markings for liposuction of the arms. In those cases with fat deposits in the posterior region of the arm, it is important to mark the new
desired plane to get with liposuction. Press the area toward the inside, until you reach the new ideal plane drawing a line under the hand

Fig. 19 The different positions for liposuction of the posterior arm region, in order to simulate the aspect of the extended arm in the various pos-
sible positions
372
Fig. 20 Liposuction in the
hypogastric and suprapubic
areas in a male patient. Skin
retraction in this region causes a
pubic lift, with a rejuvenating
effect in the genital area
long scars, we think that indications are rare. Often, results
are mediocre because of skin irregularities and an operated
look with a flat abdomen, where natural concavities and con-
vexities of the region have disappeared.
12 Markings for Abdominal Liposuction
When markings for abdominal liposuction are made, the
patient is kept in an orthostatic position, standing in front of
the surgeon who is usually sitting on a stool. After checking
that asymmetries are not due to skeletal malpositioning, we
also see if an excessive skin laxity is not present, because this
to our thought contraindicates liposuction alone. The surgeon
should also exclude the presence of umbilical or epigastric
hernias or any abdominal wall defect and previous scars.
Having excluded these problems which, of course, totally
contraindicate liposuction because of the risk of perforations,
we mark with harmonic curves the epigastric area, the meso-
gastrium, the lateral abdomen, and the lower quadrants, until
the suprapubic area is reached; occasionally, this region can
be treated, if necessary (Fig. 20). In fact, we highlight a mod-
erate aspiration of this part which might give a younger
appearance, because of an upward retraction. This effect will
be boosted by treating also the inguinal region, with a conse-
quent tissue retraction. After having marked those areas to be
treated, we delimitate fadering areas with concentric circles,
in order to maintain the natural smoothing of margins towards
the upper and lower portions of the region. An evaluation of
the quantity of fat to suction might be done by pinching the
abdominal flap, always looking at what we already took out.
The surgeon should remember to extend suction to the lateral
quadrants of the abdomen, for a real 3D remodeling.
M. Gasparotti and P. Iannitelli
13 Liposuction of the Neck
Submental liposuction is often associated with treatment of
submandibular and lateral cervical areas. Access is obtained
with two incisions just posteriorly to the ear lobules and sub-
mentally. Indications include young and middle-aged patient
(not over 45 years old), with good skin quality, without pla-
tysmal bands and subplatysmal fat deposits. Patient selection
is of paramount importance, because both in cases of exces-
sive skin laxity or thinness, tissue retraction will not be
enough to grant a desirable result. Sometimes, the deformity
can be even worsened because of skin relaxation and platys-
mal ptosis. Liposuction of the neck can be done both under
local or general anesthesia. The anesthetic solution we use
contains 500 cc of saline, 1 mg of adrenaline, 25 cc of lido-
caine 2 %, and 7–8 cc of sodium bicarbonate. Then, with a
superwet infiltration technique, we wait as usual 15 min for
vasoconstriction, and then we perform a crisscross treatment
with a Mercedes 4 mm cannula that is passed inside out sev-
eral times, through the known access incisions.
In this way, a nice thinning of the submandibular and sub-
mental flap is done, leaving a 2–4 mm of subdermal fat to
avoid excessive tissue retraction, with consequent ugly pla-
tysmal cords, typical of platysmal laxity. Here, even in mini-
mal cases, we associate a platysmal placation or in more
severe cases (often in patients over 45 years old) a conven-
tional neck or facelift.
A Reston sheet is applied over the area, with a compres-
sive garment for 4 days. After that, only for the night, the
patient will wear a protective mask, while she will do some
massages during the day. We rarely use drains here, unless an
open procedure has been associated. When some hard edema
appears, we infiltrate lidocaine every other week, making
Tridimensional Liposculpture 373

Fig. 21 Liposculpture of the

neck before and after surgery

tissue movements non-hurting and helping a good skin • Lidocaine dosage

redrapement. Topical applications of heparin will treat any • Volume of fluids given
possible ecchymosis. • Length of surgery
Massages and tissue rehydration are advisable, and sun • Type of anesthesia
exposure should be avoided for 15–20 days after surgery
because of possible hyperpigmentations (Fig. 21). Liposculpture is not without complications because:
• Even if small instruments and small incisions are used, it
is a major surgery.
14 Complications • It has risks.
• Complications may happen even in experienced hands.
Liposuction has complications, which may be very severe,
including death. The incidence is proportional to the size of Systemic Complications
the treated areas and to the volume of fat removed [16–20]. • Death
• Hypovolemic shock
Minor Complications • Anesthesia-related complications
• Small hematomas • Thrombosis-thrombophlebitis-fat embolism
• Seromas • Intra- or postoperative hemorrhage
• Minor profile irregularities • Bowel perforation
• Infection
Factors Influencing Safety During Liposuction
• Number of treated areas Hypovolemic Shock
• Volume of supernatant fat removed • Prevention: tumescent technique
• Percentage of body fat removed • Areas with sensibility alterations
• Relationship between body weight and fat removed • Spontaneous resolution after 60–90 days
374 M. Gasparotti and P. Iannitelli

Skin Pigmentations 3. Gasparotti M (1992) Superficial liposuction: a new application of

the technique for aged and flaccid skin. Aesthetic Plast Surg
• Early sun exposure 16(2):141–153
• Big hematomas 4. Gasparotti M (1992) The importance of the “G point” in superficial
liposculpting. Lipoplasty Newsletter 9:4
5. Gasparotti M (1994) Superficial liposculpture. Actuslitè de chirur-
gie esthetique, 3ème série, Edition SOFCEP
Prevention 6. Gasparotti M (1998) Oberflachliche Fettabsaugung. In: Lemperle
• Avoid sun exposure for a month following surgery. G (ed) Handbuch der 7. Aesthetischen Chirurgie. AG6 C0. KG
• Use protective filters for the next 2 months. Rudolf Diesel Strabe 3, Landsberg
• Use heparin, hyaluronidase, and k1 vitamin with ice packing. 7. Gasparotti M (1998) Superficial liposculpture. World J Plast Surg
2:1
8. Gasparotti M (1997) Three-dimensional superficial liposculpture.
Abstract 8th EURAPS meeting. Amsterdam
Local Complications 9. Gasparotti M, Lewis CM, Toledo LS (1993) Superficial liposculp-
• Envelope irregularities ture – manual of technique, 1st edn. Springer, New York
10. Alegría Perén P, Barba Gómez J, Guerrero-Santos J (1999) Total
• Adherences corporal contouring with megaliposuction (120 consecutive cases).
• Allergic reactions to tapes Aesthetic Plast Surg 23(2):93–100
• Skin pigmentations 11. Baroudi R (1984) Body sculpturing. Clin Plast Surg
• Local infection 11(3):419–443
12. Nguyen AT, Rohrich RJ (2010) Liposuction-assisted posterior bra-
• Paresthesias chioplasty: technical refinements in upper arm contouring. Plast
• Seromas and hematomas Reconstr Surg 126(4):1365–1369
13. Cárdenas-Camarena L, González LE (1998) Large-volume liposuc-
tion and extensive abdominoplasty: a feasible alternative for
improving body shape. Plast Reconstr Surg 102(5):1698–1707
Envelope Irregularities Prevention 14. Dillerud E (1990) Abdominoplasty combined with suction lipo-
• Use smooth-tip cannulas with low-medium caliber (less plasty: a study of complications, revisions, and risk factors in 487
than 5 mm). cases. Ann Plast Surg 25(5):333–338, discussion 339–343
• Deep holes inside. 15. Gonzalez-Ulloa M, Guerrerosantos J (1997) Deep 2 planed tor-
soabdominoplasty combined with buttocks pexy. Aesth Plast Surg
• Always use a small cannula first. 21:245
• Keep a 1 cm fat layer under the skin. 16. American Society of Plastic and Reconstructive Surgeons and the
• Try to suction fat in the same layer. Plastic Surgery Educational Foundation (1998) Lipoplasty (press
• What matters is what you leave and not what you take out. release: Plastic Surgery Briefing). Arlington Heights, February 9,
1998
• It is better to underdo than to overdo. 17. Kim YH, Cha SM, Naidu S, Hwang WJ (2011) Analysis of postop-
erative complications for superficial liposuction: a review of 2398
cases. Plast Reconstr Surg 127(2):863–871
18. Berry MG, Davies D (2011) Liposuction: a review of principles and
techniques. J Plast Reconstr Aesthet Surg 64(8):985–992
Bibliography 19. Franco FF, Tincani AJ, Meirelles LR, Kharmandayan P, Guidi MC
(2011) Occurrence of fat embolism after liposuction surgery with
1. Kesselring UK (1983) Regional fat aspiration for body contouring. or without lipografting: an experimental study. Ann Plast Surg
Plast Reconstr Surg 72(5):610–619 67(2):101–105
2. Gasparotti M (1992) Superficial liposculpture. In: Problems in plas- 20. Thomas M, Menon H, D’Silva J (2010) Surgical complications of
tic and reconstructive surgery, vol 2, n 3. J.B. Lippincott, lipoplasty – management and preventive strategies. J Plast Reconstr
Philadelphia Aesthet Surg 63(8):1338–1343
 Lipoabdominoplasty: Saldanha’s
Technique
Osvaldo R. Saldanha, Sérgio F.D. Azevedo,
Octávio A.L. Luz, Osvaldo R. Saldanha Filho,
and Cristianna B. Saldanha
1 Introduction
The evolution of techniques in abdominal surgery, with low
postoperative morbidity and lower complication rates, has
always motivated surgeons to search for innovations in plas-
tic surgery [1–16]. Lipoabdominoplasty was developed and
patterned as a safe and functional option with which to per-
form liposuction and abdominoplasty during the same surgi-
cal procedure, promoting the benefits of both techniques.
This technique generates a better aesthetic result and can be
learned quickly because surgeons are accustomed to per-
forming each procedure (liposuction and abdominoplasty)
separately. This technique does not involve simply using
liposuction while performing abdominoplasty; it has a much
wider concept, respecting the complete abdominal anatomy.
Traditional undermining is substituted with cannula under-
mining. As a consequence, the blood supply coming from the
abdominal perforating vessels is not stopped.
2 Anatomy
The abdominal wall skin comprises two elements: epidermis
and dermis. Beyond the dermis, the subcutaneous cellular
tissue comprises of two layers of adiposities separated by the
superficial fascia; the deeper fat layer is intimately related to
the muscles of the anterior abdominal wall through which
penetrate the vascular, lymphatic, and nervous systems.
The abdominal muscles are the rectus abdominal, exter-
nal oblique, internal oblique, transverse, and pyramidal. The
main arteries of each part of the abdominal wall are two
superior arteries, the superior epigastric artery and the mus-
culophrenic artery (branches of the internal thoracic artery),
O.R. Saldanha, MD (*) • S.F.D. Azevedo, MD • O.A.L. Luz, MD
O.R. Saldanha Filho, MD • C.B. Saldanha, MD
Department of the Plastic Surgery, Santa Cecília University,
Santos, São Paulo, Brazil
e-mail: clinica@clinicasaldanha.com.br
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_27
and two inferior arteries, the inferior epigastric artery and the
deep circumflex of the ileum (branches of the external iliac
artery) [17]. Branches of the lumbar and intercostal arteries
also help the circulation of the abdominal wall. The veins
follow the arteries’ path and nomenclature.
The lymphatic drainage is caudal to the umbilicus toward
the superficial inguinal nodes and cranial to the axillary
nodes. The nerve supply comprises the thoracoabdominal,
iliohypogastric, and ilioinguinal nerves. Lipoabdominoplasty
is based on the vascular anatomy of the abdominal wall,
especially of the perforating vessels of the rectus abdominal
muscles [18, 19].
The Scarpa fascia and part of the deep fat layer are pre-
served to achieve a complete reconstruction of the abdomi-
nal wall in the entire lower abdomen between the umbilicus
scar and pubis. It is completed when the superior flap reaches
the pubis (Figs. 1, 2, and 3).
The upper abdomen is undermined exactly between the
internal borders of rectus muscles, which correspond to the
area of diastasis. It preserves around 80 % of perforating
arteries, veins, lymphatics, and nerves, as shown by Munhoz
Scarpa fascia
Rectus abdominus and deep fat
layer
Perforating blood
vessels
Fig. 1 Preservation of Scarpa fascia and partial deep fat layer in the
lower abdomen to accommodate the abdominal flap
375
376
Fig. 2 Preservation of Scarpa fascia and partial deep fat layer in the
lower abdomen to accommodate the abdominal flap
Fig. 3 Preservation of Scarpa Fascia and partial deep fat layer in the
lower abdomen to accommodate the abdominal flap
et al. [20, 21], who demonstrated in a Doppler ultrasound
study that the perforating vessels mapped in the preoperative
period were preserved. This finding validates the hypothesis
that this technique results in a lower percentage of complica-
tions resulting from flap ischemia.
De Frene et al. showed that raising perforator flaps after
liposuction of the donor sites is possible. In 2006, they per-
formed breast reconstruction using perforator flaps in patients
who had previously undergone abdominal liposuction [22].
The skin and rectus abdominal muscle is innervated by
the anterior branches of the 6th to the 12th intercostal nerves
that run along the abdominal perforating vessels. The loss of
sensitivity is significant after classical abdominoplasty, as
shown in many studies.
3 Surgical Techniques
3.1 Evolution of Undermining
History shows a progressive undermining of the abdominal
wall from 1899 to 1957 [1–3], when the extensive undermin-
ing was standardized by Vernon to facilitate umbilicus trans-
position. In 1985, Hakme presented a new approach for the
O.R. Saldanha et al.
abdominal lipectomies, called the miniabdominoplasty tech-
nique and consisting of liposuction of the entire abdomen
and flanks, associated with the elliptical resection of the
suprapubic skin and plication of the supraumbilical and
infraumbilical muscles, without relocating the umbilicus [8].
In 1991 and 1995, Matarasso focused on the complications
of combined liposuction and abdominoplasty methods, pre-
senting two articles that recommended safe areas of liposuc-
tion [9, 10]. In these studies he considered the back and the
flanks safe areas and did not regard the lateral region of the
abdomen as safe; the central region of the abdomen was con-
sidered prohibited for liposuction [23].
In 1995, Lockwood reported the high lateral tension
abdominoplasty, in which he used the Scarpa fascia to
decrease the tension of the skin closure [12, 13]. Since the
1990s, the undermining has decreased in amplitude because
of a large number of complications (seroma, hematoma, and,
most of all, necrosis), reaching zero in 1992 with the publi-
cation regarding abdominoplasty mesh undermining by
Illouz [11, 24, 25]. The trend of abdominolipoplasty without
or with small undermining continued until 1999, when
Shestak [14] and Avelar [15] presented the partial abdomino-
plasty method, with no undermining, associated with
liposuction.
In 2001, using the term lipoabdominoplasty for the first
time and with the publication of this technique, Saldanha
standardized a selective undermining along the internal bor-
ders of the rectus muscles, corresponding to approximately
30 % of the traditional undermining, thus preserving the
abdominal perforating vessels, using liposuction and abdom-
inoplasty safely during the same surgical procedure [26–30].
This selective undermining is maintained to this day. Figure 4
shows the evolution of undermining in abdominoplasty from
1899 to 2009.
lipoabdo
Kelly Vernon Illouz Saldanha minoplasty
100
90
80
70
Isolated area
60
50
40
30
20
10
0
1899 1957 1990 1992 2000 2009
Year
Fig. 4 Percentile variations of diastasis which have greatly decreased
with Saldhana resulting in less skin necrosis
Lipoabdominoplasty: Saldanha’s Technique 377

4 Lipoabdominoplasty: Saldanha’s
Technique

4.1 Fundamentals of the Technique

Superficial liposuction introduced by Souza Pinto was one of

the fundamental principles of lipoabdominoplasty [31]. This
procedure gives more mobility to the abdominal flap so that
it can slide down easily and reach the suprapubic region. The
second principle is the anatomical study of the exact local-
ization of the perforating abdominal vessels so that they can
be preserved during the procedure [32].

4.2 Patient Selection Fig. 6 Oblique marking (7–8 cm)

All patients for whom traditional abdominoplasty is indi-

cated may undergo lipoabdominoplasty. From 2000 to
2009, lipoabdominoplasty was performed on 588 patients
(11 males and 577 females) with an average age of 36
years.

5 Surgical Steps

5.1 Surgical Marking

The abdomen is marked in the traditional manner as described

by Pitanguy [5], with 12–16 cm horizontally (Fig. 5) and
7–8 cm obliquely, with approximately 40–45° of inclination
on each side (Fig. 6), in the direction of the iliac crests. The
distance from the vaginal to the horizontal marking is 6–7 cm
(Fig. 7). Fig. 7 Initial distance from the pubis (6–7 cm)
For better orientation at the beginning of tunnel under-
mining, the diastasis is marked in advance. If necessary, the
dorsal areas are marked for liposuction (Fig. 8).

Fig. 5 Horizontal marking (12–16 cm) Fig. 8 Previous demarcation of diastasis

378
5.2 Infiltration
The tumescent technique is used by infiltrating the abdomi-
nal region with saline solution and adrenaline (1:500,000),
with an average 1–1.5 L total (Fig. 9).
5.3 Epigastric and Subcostal Liposuction
To safely perform liposuction, the patient is placed in a
hyperextended position on the surgical table. The liposuction
starts on the supraumbilical region with a 3- and 4-mm can-
nula, removing the fat of the deep and superficial layers,
going on to the flank. As in classic liposuction, the fat thick-
ness is maintained to about 2.5 cm to avoid vascular impair-
ment and contour deformities (Fig. 10).
5.4 Lower Abdomen
Before removing the excess skin, to facilitate visualization and
preservation of the Scarpa fascia, all of the fat in the superficial
Fig. 9 Infiltration
Fig. 10 Superior abdominal liposuction
O.R. Saldanha et al.
layer and some of the fat in the deep layer need to be aspirated
in the lower abdomen using a 6-mm cannula (Fig. 11). The
flap descent is evaluated and the surgeon proceeds with isola-
tion of the umbilicus and total resection of the infraumbilical
skin, as in traditional abdominoplasty (Fig. 12). When neces-
sary, complementary open liposuction is performed to remove
more fat below the Scarpa fascia to create a homogeneous sur-
face to accommodate the superior flap (Fig. 13).
5.5 Selective Undermining
The undermining of the tunnel is started in the median line of
the upper abdomen, between the internal borders of the rec-
tus abdominal muscles, with care taken to not overpass them,
because in this area one might cut off the abdominal perfo-
rating vessels (Figs. 14 and 15a, b). The wider the diastasis,
the wider the tunnel, because the perforating vessels follow
the separation of the muscles.
Tunnel undermining may reach the xiphoid, depending
on the necessity of the plication. For a better view of the
Fig. 11 Lower abdominal liposuction
Fig. 12 Evaluation of flap descent
Lipoabdominoplasty: Saldanha’s Technique 379

Fig. 13 Open liposuction

Fig. 15 (a) Perforating vessels. (b) Removal of Scarpa fascia fuse

Fig. 14 Preservation of Scarpa fascia

anatomical structures and to facilitate the plication, a retrac-

tor was created that amplifies the surgical area and avoids
trauma on the edge of the flap (Figs. 16 and 17).

5.6 Preservation of the Scarpa Fascia

In the lower abdomen, all of the superficial fat layer should be

aspirated to facilitate visualization and preservation of the
Scarpa fascia, leaving it intact after removal of the lower
abdominal skin. The preservation of the Scarpa fascia is very
important for many reasons. It causes less bleeding because of
the preservation of the inferior perforating vessels; it is a
homogeneous support for the upper flap, which becomes thin-
ner on its descent; and it provides smaller scars laterally and
offers better adherence between the flap and the deep layers. Fig. 16 Selective undermining of the tunnel
380 O.R. Saldanha et al.

Fig. 17 Saldanha’s retractor

Fig. 18 Resection of the infraumbilical fuse

5.7 Resection of the Infraumbilical Fuse

and Rectus Muscle Plication

In the median infraumbilical line, a vertical fuse that con-

tains the Scarpa fascia and adipose tissue is removed to
expose the internal edges of the rectus abdominal muscles
and to perform the plication from the xiphoid to the pubic
symphysis (Figs. 18 and 19).

5.8 Omphaloplasty

The star-shaped omphaloplasty technique is used, which is a

cross-demarcation on the abdominal wall and a rectangular
demarcation on the umbilical pedicle. The cardinal points of
the umbilical pedicle are sutured, accommodating them-
selves on the cruciform incision of the abdominal wall. The Fig. 19 Plication
resulting scar is performed in continuous Z-plasty that offers
little possibility of retraction (Fig. 20a, b).
5.10 Dressing

5.9 Suture of the Layers
The suture of the abdomen is performed in two layers
using 3-0 Monocryl (Ethicon, Somerville, NJ) on the deep
layer and 4-0 Monocryl on the subdermis, attempting to
take the tension off the midline skin closure by placing
more tension laterally, as recommended by Lockwood [12,
13]. The skin is sutured with 5-0 nylon, with separate
stitches (Figs. 21 and 22). The continuous aspiration drain
(4.2 mm) is used for 1 or 2 days (Fig. 23). The operation
takes approximately 2 h and the patient stays in the hospi-
tal for 1 day.
To dress the wound, we use Micropore surgical tape (3M, St.
Paul, MN) on the suture, which is changed on the third and
eighth days after surgery, when we remove the stitches,
except those on the umbilicus, which are removed on the
12th day after surgery. The patient needs to use compressive
mesh for 20 days after surgery.
5.11 Postoperative Period
Patients who undergo lipoabdominoplasty present an
intermediary recovery between an abdominoplasty and a
Lipoabdominoplasty: Saldanha’s Technique
Fig. 20 (a) Marking the “star technique” omphaloplasty and incision.
(b) Final aspect of umbilicus
Fig. 21 Suture of the layers and marking of the skin to be removed
liposuction, because the lipoabdominoplasty is less inva-
sive and causes little vascular and nervous trauma other
than presenting a discrete dead space. These factors
together result in less morbidity. With this method, patients
return to their social and professional activities earlier.
5.12 Results
The safe association of liposuction and abdominoplasty dur-
ing the same surgical procedure improves the results, includ-
381
Fig. 22 Obtaining a lower scar 6–8 cm from the vulvar commissure
Fig. 23 Aspiration drain
ing a greater reduction in abdominal measures and better
body contour (Figs. 24a–f). Patient satisfaction resulting
from abdominal rejuvenation leads to an increase in surgical
demand and a decrease in the need for surgical revisions
(Figs. 25, 26, 27, and 28).
We compared the incidence of complications with tradi-
tional abdominoplasty to that with lipoabdominoplasty. The
1083 patients who underwent abdominal surgery as men-
tioned in this chapter were operated on and followed by the
senior author (O.R.S.) from 1979 to 2009.
From 1979 to 2000, the senior author performed 494 tra-
ditional abdominoplasty operations. In 2000, he began to
develop lipoabdominoplasty and in 2001 it was standard-
ized, corresponding to 588 procedures until 2009 (Table 1).
In that year only one traditional abdominoplasty was per-
formed, which was a specific case of skin excess in a patient
who had undergone bariatric surgery (Table 2).
In the first 10 years of technique implementation, there
was an increase of 100 % in the abdominal interventions
382
a b
c d
e f
Fig. 24 Case 1. Status of the patient preoperatively (a–c) and postop-
eratively (d–f)
made by the senior author (before 2000, there was an average
of 35 patients per year and in 2009, an average of 70 patients
per year). The same does not apply to interventions in other
parts of the body. There was a 50 % reduction in the need for
surgical revisions in the same period.
A decrease in the final scar extension was observed
when compared with the initial marking in 30 % of
patients. The initial line always measured 28 cm in length:
12 cm horizontal and 8 cm oblique on each side. In the 588
patients, 176 had a final scar between 25 and 27 cm, with
an average reduction of 2 cm from the initial marking. This
is attributable to the traction that the Scarpa fascia makes
on the skin. The graceful shape of the umbilicus scar has
been evaluated by the team and the patients as good or
excellent.
O.R. Saldanha et al.
a b
c d
e f
Fig. 25 Case 2. Status of the patient preoperatively (a–c) and postop-
eratively (d–f)
5.13 Discussion
Lipoabdominoplasty has produced a significant reduction in
complications such as seroma, hematoma, and flap necrosis.
This technique avoids two-stage procedures (abdomino-
plasty and isolated liposuction) in most indications for an
abdominoplasty procedure. Using the conservative approach,
we can safely perform liposuction in the abdominal and cos-
tal regions to obtain a harmonious body contour, providing
excellent aesthetic results, with low morbidity.
Lipoabdominoplasty results in a greater reduction of the
abdominal measures and better body contour, not only
because of the traditional removal of skin but also because of
Lipoabdominoplasty: Saldanha’s Technique
a b
c d
e f
Fig. 26 Case 3. Status of the patient preoperatively (a–c) and postop-
eratively (d–f)
a decrease in the fat layer located in the abdomen and flanks
by using liposuction.
The 100 % increase in the demand for abdominal surgery,
unlike with other procedures, shows patient acceptance of
the technique and how patients have recognized the improve-
ment it has brought. The decrease in the need for surgical
revisions is another fact that motivates more surgeons to per-
form this technique. The use of vacuum drainage is impor-
tant for draining the liquid injected during liposuction.
In addition, the technique results in the preservation of
suprapubic sensibility, quicker healing, faster postoperative
recovery, lower morbidity, and a better-appearing shape of
the umbilicus scar. It also proves to be particularly indicated
for smokers because of the preservation of the perforating
abdominal vessels.
Traditional abdominal plastic surgery is associated with a
high rate of morbidity, because of the necessity for undermining
383
a b
c d
e f
Fig. 27 Case 4. Status of the patient preoperatively (a–c) and
postoperatively (d–f)
large areas of the flap where the perforating vessels are sec-
tioned, taking into consideration that they represent 80 % of the
blood supply of the abdominal wall according to the literature
on this subject. Lipoabdominoplasty is based on the selective
undermining of the abdominal flap on the superior medial line,
preserving the great majority of the arteries, lymphatic vessels,
veins, and nerves, which reduces the incidence of complica-
tions. However, a progressive adaptation of this technique is
necessary, starting with cases in which there is a large amount
of skin flaccidity and sufficient adipose accumulation to permit
liposuction and easy liberation of the flap.
This technique is not simply using liposuction while per-
forming abdominoplasty but represents a much wider
384 O.R. Saldanha et al.

a b concept, respecting the complete abdominal anatomy.

Lipoabdominoplasty is based on the selective undermining
of the abdominal flap in the superior medial line, resulting in
the preservation of arteries, veins, lymphatic vessels, and
nerves. Classic undermining has been replaced with cannula
undermining; as a result, the blood supply from the abdomi-
nal perforating vessels is preserved. This represents an
important way of ensuring patient safety.

6 Complications
c d
Following the surgical steps systematically and carefully
reduces considerably such complications as abdominal flap
ischemia and skin necrosis, which are difficult to treat and
which can jeopardize the doctor-patient relationship (Fig. 29).
The reduced incidence of seroma (from 60 to 0.4 %,
p < 0.0001), epitheliolysis (from 3.8 to 0.2 %, p = 0.0003),
dehiscence (from 5.1 to 0.4 %, p < 0.0001), and necrosis
(from 4 to 0.2%, p = 0.0002) has statistical significance.
Although the incidence of hematoma was reduced (from 0.6
to 0.2 %) and the incidence of deep venous thrombosis/pul-
e f
monary embolism remained the same (0.2 %), we cannot
consider these findings statistically significant because of the
small number of complications. All of these rates can be
observed in a comparison of traditional abdominoplasty with
lipoabdominoplasty both performed by the authors.
In the same way, the percentage of surgical revisions
decreased from 20 to 10 % when only lipoabdominoplasty
was performed, remaining so for 9 years. The cases of surgi-
cal revision resulting from complementary liposuction and
postoperative skin flaccidity (1.8 %) corresponded to patients
who had undergone previous bariatric surgery and who pre-
Fig. 28 Case 5. Status of the patient preoperatively (a–c) and postop- sented a great amount of flaccidity. There was a need for
eratively (d–f)

Table 1 Personal statistics of abdominal surgeries

1979–1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009a Total
Abdominoplasty 469 25 – – – – – – 1 – – 495
Lipoabdominoplasty – 15 45 55 64 62 65 68 71 75 68 588
a
Surgeries until September 2009

Table 2 Surgical revision in lipoabdominoplasty

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Primary total = 588 15 45 55 64 62 65 68 71 75 68
Scars 3 5 4 3 4 3 3 4 2 1
Skin flaccidity – – 1 2 1 1 1 2 – 1
Insufficient liposuction – – 1 2 2 1 1 1 1 –
Excessive liposuction – – – – – – – – – –
Infection – – – – – – – – – –
Other causes – – – – 1 – – – – –
Total 3 5 6 7 8 5 5 7 3 2
Percentage 20 % 11 % 11 % 11 % 13 % 8% 7% 10 % 4% 3%
Lipoabdominoplasty: Saldanha’s Technique
Fig. 29 Complications with 60,0%
traditional abdominoplasty vs.
lipoabdominoplasty
Complications
0,4%
Seroma
surgical revision of scars in 6.5 %, which represents 63 % of
surgical revisions. For this reason, since 2001 we have been
performing only lipoabdominoplasty.
Pearls
• A better body contour is achieved because liposuc-
tion decreases the abdominal measurement.
• There is less morbidity because of the preservation
of perforating vessels and the absence of dead space.
• There is a lower percentage of complications.
• It is easy to perform because all surgeons are used
to doing liposuction and classical abdominoplasty.
• The abdomen is rejuvenated with a more natural
profile.
• The suprapubic sensitivity is preserved.
• There is faster postoperative recovery and a shorter
scar.
• It can be associated with vibroliposuction or ultra-
sound liposuction.
• It is safe for patients who smoke or obese patients
who have previously undergone bariatric surgery or
abdominoplasty.
Pitfalls
• Initially, a longer time period is needed to perform
the surgery.
• The procedure should not be performed on patients
with a large hernia or eventration.
• A learning curve is required to assimilate the new
procedure.
385
Traditional abdominoplasty
Lipoabdominoplasty
3,8% 5,1% 4,0%
0,2% 0,4% 0,2% 0,6% 0,2% 0,2% 0,2%
Diastasis Dehiscence Necrosis Hematoma Deep vein
Thrombosis, pulmonary embolis
Disclosure None of the authors has a financial interest to declare in
relation to the content of this chapter.
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 Lipofilling and Correction
of Postliposuction Deformities
K. Ning Chang
1 Introduction
The introduction of suction-assisted lipectomy (SAL) ush-
ered in a new era of body-contouring surgery. The technique
has provided a simpler, safer, and more effective method of
improving the body contour than what was available before.
Subsequent refinement and development, including the
use of wetting solution, large-volume liposuction, and
ultrasound-assisted lipoplasty (UAL), have further enhanced
our ability to contour the body. Today, liposuction is one of
the most frequently performed aesthetic operations. Good
results are usually expected, and dramatic results are not
uncommon. However, these procedures may produce com-
plications and aesthetically undesirable results. These prob-
lems can be grouped into four general categories:
• Skin problems
• Contour problems
• Disproportion
• Skin excess
Skin problems include discoloration, loss of smoothness,
textural changes, atrophy, wrinkling, and scarring. Contour
problems include indentation, depressions, grooves, waves,
dents, divots, dimples, and protuberances. Aesthetic dispro-
portion is characterized by altered proportion in various parts
of the body, rendering a disharmonious, unnatural, and dis-
pleasing look. For example, excessive removal of fat in a wom-
an’s medial thighs may result in an emaciated or masculinized
appearance. Excessive removal of the fat from the waist results
in configuration of apparent widening of the hips and buttocks.
Excessive skin results from a discrepancy between the overly-
ing skin envelope and the underlying subcutaneous tissue and
fat. The junction of the lower buttock and upper posterior thigh
K.N. Chang, MD
Private Practice, California Pacific Medical Center, San Francisco,
CA, USA
e-mail: kningchang@hotmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_28
is prone to this type of problem. Some of these changes have
been referred to as postliposuction contour irregularities.
The outcome of lipoplasty is influenced by many vari-
ables including the skin condition, the patient’s age, extract-
ability of the fat, the equipment used (SAL, UAL,
power-assisted lipoplasty [PAL]), the amount of infiltration
of wetting solution, artistic planning, surgical execution, and
postoperative care. Careful planning, individualizing treat-
ment for a particular anatomical situation in each patient,
and understanding the potential pitfalls are some of the keys
to preventing postliposuction contour irregularities.
There are many factors which lead to undesirable out-
come. A common cause of contour irregularity is overresec-
tion of adipose tissue, which may result from a cannula that
is too large or from making too many passes with the cannula
in the same location. In some patients, especially fair, thin-
skinned woman, the adipose tissue may be loose and prone
to overresection.
The incision or immediately adjacent zone may be sub-
jected to excessive fat removal due to repeated cannula move-
ments in and out of the area. Wetting solution renders the fat
more easily removed. When excessive amount of wetting solu-
tion is infiltrated in an area that is loose and not fibrous, fat
extraction can easily exceed what is necessary to achieve the
desired results. Infiltration of excessive wetting solution, com-
bined with the application of a cannula in the subdermal layer,
may result in diffuse, multicentric contour irregularities. To
ensure a good surgical outcome, one should leave a smooth,
unscarred layer of adipose tissue beneath the skin and dermis.
Underlying bony prominence may lead to erroneous assess-
ment of the amount of remaining adipose tissue; overresection
may occur as a result. Examples are medial condyle of the
femur at the knee and posterior iliac crest region. Uneven
resection may occur where more fibrous adipose tissue is jux-
taposed with looser adipose tissue. The periumbilical area is
an example in which dense subcutaneous tissue around the
umbilical stalk changes into softer adipose tissue of the lower
abdomen. Similarly, a preexisting abdominal surgical scar
may interfere with smooth fat extraction near the scar.
387
388 K.N. Chang

Suboptimal incision placement may lead to unsmooth

results. Ideally, an incision should permit the application of
smooth, radiating cannula movements appropriate for the
three-dimensional anatomy. When the cannula is torqued or
forced to go around a curved surface, the result may be sub-
optimal. To avoid the formation of a trough, two incisions
may be placed at 90° angles from each other to form a criss-
cross pattern. In circumferential liposuction or liposuction of
extensive body surfaces, variable-sized grid pattern mark-
ings can be drawn on the skin surface intraoperatively for the
purpose of planning incision placement and systematic
removal of the subcutaneous fat [1].
Removal of adipose tissue from inappropriate level of the
subcutaneous layer may contribute to unsatisfactory results.
For example, when the fat is removed from the deep layer of
the lower buttock and the upper posterior thigh, the support
is lost and the buttock becomes ptotic. Improvement of the
upper posterior thigh (subgluteal region) and the anterior
superior knee is accomplished by removal of more superfi-
cially located fat.
Incorrect preoperative surgical markings may lead to
unsatisfactory results. The shape of the body may change Fig. 1 Superficial and deep adipose layers of the trunk
from standing to recumbent position, or after the wetting
solution is infiltrated. Without guidance of proper surgical
markings, extraction of fat may be compromised. important to leave a smooth, healthy layer of fat beneath the
Lack of proper feathering at the periphery of the liposuc- skin after liposuction.
tion site may lead to visible demarcation between the treated Subcutaneous fascia, or the superficial fascia system, is
and untreated area during the immediate postoperative period the fibrous connective tissue network that, depending on
or in the future when the shape of the body changes. the location, contains single or multiple horizontal mem-
When UAL is used, excessive application of ultrasound branous layers and vertically oriented extensions attaching
energy, mechanical impact, or thermal effect may lead to to the subdermal layer above and the deep fascia layer
prolonged edema, overresection, and tissue damage. below. Varying zones of adherence of the superficial fascia
Similarly, other modality of fat removal may also deliver system extend over the trunk and extremities. The encased
excessive energy to the tissue. fat produces bulges, valleys, plateaus, creases, and folds.
Uneven or tight postoperative compression may lead to The most adherent zones exist as skin creases and valleys,
temporary or permanent deformation of the skin and the sub- such as the inframammary fold, groin crease, gluteal
cutaneous tissue. In more severe cases, scarring and tissue crease, and anterior, posterior midline, and lateral gluteal
necrosis may result. depression. Zones of least adherence are the bugles of the
truncal area and the extremities, where the superficial fas-
cia system forms a roof over the localized deep fatty layer.
2 Anatomy of the Subcutaneous Intermediate zones of adherence exist in all areas of the
Adipose Tissue trunk and extremities without significant deep fat [3].
Planning of liposuction should take into account the loca-
The subcutaneous adipose tissue of the trunk and the extrem- tion of certain zones of adherence. Excessive liposuction
ities is organized into a continuous superficial layer and in the zones of adhesion may result in fibrosis and indenta-
localized deep fatty layer, which is present in the abdomen, tions [4] (Fig. 2).
paralumbar, and gluteal-upper thigh regions. These are the Clinically, the extractability of fat varies, depending on
locations of undesirable bulges commonly subjected to lipo- each individual, gender, and anatomical locations. The fol-
suction (Fig. 1). Extractability of fat depends on the density lowing is a list of body regions ranked in increasing effort
and strength of the connective tissue that encases the fat. required to extract the fat: medial knees, lateral thighs, but-
Loosely organized deeper fat tends to be more easily removed tocks, central lower abdomen, medial thighs, upper arms,
than the more compact superficial fat [2]. In lipoplasty, calves, ankles, hips, waist, upper abdomen, flanks, chest
depending on the aesthetic goals, both the superficial fatty wall, and the back. In general, it takes more effort to extract
layer and the deep layer are targeted for fat extraction. It is the fat from men than women.
Lipofilling and Correction of Postliposuction Deformities 389

Fig. 2 Localized deep fatty layer of the trunk, extremities, and varying zones of adherence of the superficial fascia system

3 Patient Evaluation

During consultation with the patient regarding secondary proce-

dures to correct postliposuction irregularities, the surgeon obtains
information regarding the patient’s preoperative body appear-
ance, the desired changes, the actual results obtained, anesthesia
technique, surgical technique, complications, and other details of
surgery, if known. The patient is asked about specific areas of
concern and the improvement she/he is seeking.
Physical examination includes assessment of the thickness
of the subcutaneous fatty layer by means of the skin pinch test.
The underlying musculoskeletal contour is assessed by palpa- Fig. 3 The ideal contour to be restored by fat grafting and additional
liposuction
tion and by asking the patient to contract the muscles and pose
in various body positions. Laxity and sagging are assessed by
lifting the skin up against the gravitational pull and by observ-
ing body contours in the upright, reclining, sitting, and flexed tive. Patient may express strong feeling for or against der-
positions. Areas of fat excess and fat deficiency are deter- molipectomy, which results in much longer scars compared
mined. The location of cannula entry sites from the previous with the original liposuction incisions.
operation is correlated with the location of fat deficiency.
The surgeon visualizes the ideal contour, determines the
sites for harvesting the fat, and discusses the surgical plan 4 Procedure for Treating
with the patient (Fig. 3). Postliposuction Contour Irregularities
Variable retention of the fat graft, realistic expectations,
limitations, and potential need for additional procedures, Minor contour irregularities can be treated by limited addi-
which may be major or minor financial cost, are all thor- tional liposuction, performed under local anesthesia or intra-
oughly discussed. For major contour irregularities, both venous sedation. Autologous fat transfer is used to correct
early (3–6 months) and late intervention appear to be effec- contour problems due to fat deficiency [4–9].
390
Liposhifting is another method of achieving autologous
fat transfer. A cannula with expanded tip dislodges and loos-
ens the fat (Becker tip cannula, Wells Johnson, USA).
Subcutaneous tunnels are created in adjacent area of fat defi-
ciency. The fat from the protuberant areas is redistributed
into the deficient areas using manual massage with or with-
out power-assisted cannula [9–11].
The more severe and complex cases of postliposuction
contour irregularities require systematic approach which
includes:
1. Liposuction of areas of protuberance
2. Liposuction around the areas of depression
3. Simultaneous fat grafting
4. Dermolipectomy
The technique described below has the advantage of being
simple and safe. Fat collection, preparation, and injection
use commonly available equipment. Most patients have ade-
quate amount of fat available for harvesting. Autologous fat
grafting has been used successfully for replacement for vol-
ume deficiency in various body sites including the abdomen,
thighs, hips, waists, buttocks, arms, breasts, and knees.
Certain anatomical conditions tend to promote better fat
retention. These conditions include absence of dense subcu-
taneous scarring, preservation of good quality of the skin,
gentle slope in the area of indentation, and abundance of sub-
cutaneous fatty tissue in and around the area of depression.
Some patients have extensive multifocal indentations and
dense subcutaneous fibrosis. These cases may benefit from a
combination of liposhifting and fat grafting.
4.1 Operative Techniques
A detailed topographical contour map is essential to the
planning and execution of the corrective surgery. Direct
inspection of the body and inspection of photographs com-
plement each other to render the most accurate preoperative
drawing. Some defects are better seen on photographs than
with direct inspection of the patient. Sometimes, the oppo-
site is true. Different lighting techniques may reveal different
information about the contour irregularities. Overhead ceil-
ing lighting alone, without any camera-mounted flash device,
can be very informative and easy to reproduce for postopera-
tive comparison (see Case 2 after).
Areas of maximal depression, areas of maximal protuber-
ance, and adjacent transition zones are indicated with skin
markers of different colors such as red and black. The markings
should also reflect the differences in the amount of fat that
needs to be removed in different areas. The markings are per-
formed with the patient in upright position. Digital photographs
with the surgical markings are produced for intraoperative
K.N. Chang
viewing. After surgical prepping and before the commence-
ment of corrective liposuction, areas requiring fat grafting are
tattooed with methylene blue in order to maintain accurate sur-
gical markings intraoperatively. Otherwise, the markings may
be lost after the liposuction phase (various surgical markings
are illustrated in the following case presentation).
In planning the cannula entry sites for corrective liposuc-
tion, the surgeon should select the most direct approach to
the areas to be aspirated. Attempts to hide the incisions may
compromise cannula movement and the final results.
Pretunneling before fat extraction facilitates localization of
the excess fat, helps to establish the correct cannula pathway,
avoids unwanted fat removal, and maximizes the accuracy of
fat extraction. It is extremely important to avoid overresec-
tion in corrective liposuction.
During the harvesting of fat, the infiltration of wetting
solution is minimized in order to obtain fat of maximal solid-
ity. Lidocaine 0.25 % with 1:400,000–1:800,000 epinephrine
is injected with a 22-gauge spinal needle by hand. Infiltration
into all the operative sites is minimized in order to facilitate
intraoperative evaluation of the contour, as fat is aspirated or
added. General anesthesia is used in patients with more
extensive and complex problems. The use of minimal wet-
ting solution also reduces the chance of overresection.
The fat is collected by pouring it directly from the patient
end of the liposuction tubing, or by an interposed sterile
specimen trap (Fig. 4). To optimize the quality of the fat used
for reinjection, the vacuum is reduced to 26–28 in. of mer-
cury during fat harvesting. The fat is allowed to settle, and
the liquid portion is discarded. No special processing is
required (Fig. 5). If the fat is dilute or if the amount is small,
a centrifuge or absorbent gauze can be used to concentrate
the fat.
4.2 Fat Grafting
Prior to fat grafting in areas where there is dense subcutane-
ous scarring and adhesion, a blunt-tipped cannula without
suction may be passed beneath the area of depression to
make multiple tunnels.
Fat is injected with a small blunt-tipped cannula with an
outside diameter of 1.5–1.8 mm or a 16- or 18-gauge
hypodermic needle (Fig. 6). A blunt-tipped cannula is
preferred because it is less likely to cause bleeding during fat
injection. A sharp needle offers the advantage of more pre-
cise and effective fat deposition, especially in densely fibrotic
areas or in the superficial layer of the skin.
Sometimes, the surgeon can identify the original incision
through which the overresection was performed. The same
incision can be used for fat grafting.
The fat is injected in small increments, in multiple passes,
and at multiple depths. The path of the fat injection may be
Lipofilling and Correction of Postliposuction Deformities 391

parallel or crisscross as needed. Fat injection may be carried

out as the reversal process of fat extraction in liposuction.
Deposition starts where the most severe indentation is situated.
The deposition is performed in even and incremental fashion.
During the injection, frequent visual inspection of progressive
changes in the contour and skin pinch test provide additional
means of assessing the adequacy of fat replacement. The aim of
the corrective surgery is to create a smooth contour while the
patient is on the operating table. In the areas of fat grafting,
some degree of overcorrection is acceptable. Excessive tissue
turgor or overcorrection is avoided (Fig. 7).
Postoperatively, compression garment is not used in order
to prevent any pressure and distortion in the fat-grafted areas.
Postoperative manual massage is applied when there is firm-
ness, which may result from large amount of fat deposition.
The results of surgical correction of postliposuction con-
tour irregularities using corrective liposuction and autolo-
gous fat grafting are presented in the following sections.
Some cases are simple; others are more complex. Some
cases involve contour irregularities in multiple sites of the
body. Cases are presented in the following areas: abdomen,
waist, hips, inner, outer thighs, and knees.

4.3 Case Example

Fig. 4 Interposed sterile specimen trap for fat collection

Case 1 This 30-year-old woman presented with indenta-
tions in the lower abdomen as a result of previous liposuction
(Figs. 8 and 9).

Fig. 5 Semi-solid fat ready for transfer Fig. 7 Restoration of the ideal contour by fat grafting and liposuction

Fig. 6 Blunt-tipped cannula for fat transfer

392
Fig. 8 Front view: indentation of lower abdomen
Fig. 9 Oblique view: indentation of lower abdomen
K.N. Chang
Fig. 10 Preoperative markings of areas of fat grafting and liposuction
Correction of the abdomen consisted of autologous fat
grafting to the lower abdomen in areas marked by solid black
and additional liposuction in the lower, mid-, and upper abdo-
men areas with “X” marks and cross-hatching. Transitional
zone from the areas of maximal indentation to the areas of
maximal protuberance was left without markings (Fig. 10).
Sixteen months after the corrective surgery, the abdomi-
nal contour was improved (Figs. 11 and 12). Subsequently,
the patient requested and received minor additional liposuc-
tion to reduce the periumbilical fullness.
Case 2 This 40-year-old woman underwent liposuction
with tumescent technique. She presented with postliposuc-
tion contour irregularities of the abdomen and the waist.
Her condition consisted of a large area of indentation in the
right lower abdomen and multiple areas of indentation and pro-
tuberance in the mid- and upper abdomen. There is a sharp
linear indentation in the right upper quadrant. Photographs
were taken preoperatively using camera-mounted flash
(Figs. 13 and 14). Another preoperative photograph was taken
without any flash, the only source of light being ceiling fluores-
cent light. This picture revealed the indentation in the right
upper quadrant and upper mid-abdomen more distinctly than
the photo taken with flash (Fig. 15).
In the preoperative markings, the solid black areas indi-
cate areas to receive autologous fat grafting. Cross-hatching
and “X” marks indicate areas of additional liposuction. A
Lipofilling and Correction of Postliposuction Deformities 393

Fig. 13 Multiple indentation, protuberance, and skin discoloration:

front view

Fig. 11 Postoperative front view with restoration of volume

Fig. 14 Multiple indentation, protuberance, and skin discoloration:

oblique view

Fig. 12 Postoperative oblique view with restoration of volume

394
Fig. 15 Enhanced view of linear indentation in the right upper quadrant
Fig. 16 Preoperative markings indicating areas of fat grafting (solid
black) and areas of liposuction (“X” marks)
3-mm cannula was used to aspirate the lower abdomen and
the suprapubic area. The upper abdomen was aspirated
with 2.4-mm cannula. A series of tunnels were made
K.N. Chang
Fig. 17 Front view: postoperative result at 14 months
beneath the skin of depressed areas using 3-mm blunt can-
nula without suction in preparation for fat grafting. Eighty
cc of fat was injected into the right lower abdomen. One
hundred thirty cc was injected into the supraumbilical and
upper abdominal areas. The donor sites of the fat consisted
of the abdomen, suprapubic area, and the posterior iliac
crest areas (Fig. 16).
The postoperative course was noted for swelling and sub-
cutaneous firmness in the right lower quadrant area, which
responded to massage and time. There was improvement in
the appearance of the entire abdomen 14 months postopera-
tively (Figs. 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18).
The sharp indentation in the right upper quadrant required
additional liposuction and autologous fat injection 14 months
and 6 years after the initial corrective procedures. Each time,
approximately 3.5 cm3 of concentrated fat was injected. An
18-gauge needle was used to deposit the fat during the last
procedure. The pre- and postoperative results obtained fol-
lowing the two minor procedures are shown (Figs. 19 and
20). Over 6 years and 3 months time period, there is an
improvement in the blotchy, discolored appearance of her
abdominal skin.
Case 3 This 37-year-old woman presented with several
areas of postliposuction contour irregularities including the
right mid-lateral thigh and lateral hip (Fig. 21). Preoperative
markings indicate areas of fat removal in the distal lateral
Lipofilling and Correction of Postliposuction Deformities 395

Fig. 20 Postoperative results after additional two minor procedures to

the right upper quadrant

Fig. 18 Oblique view: postoperative result at 14 months

thigh, upper lateral thigh, hip, and waist area. The area of
maximal indentation and the transitional zones are indicated
by solid and shaded red color, respectively (Fig. 22). The
right lateral mid-thigh was treated with 97 cm3 of fat, which
entirely came from the abdomen. The right lateral hip
received 40 cm3 of fat. At 1 year follow-up, the indentations
in the mid-lateral thigh and the hip were improved (Fig. 23).

Case 4 This 55-year-old woman presented with multiple

areas of postliposuction contour irregularities including
bilateral posterior iliac regions, lateral thighs, and the lateral
hip areas. Her surgical correction consisted of liposuction
around the areas of indentation and autologous fat grafting
(Figs. 24 and 25).

The amount of fat grafting to each area is as follows:

60 cm3 each to the right and left posterior iliac crest areas,
110 cm3 to the left lateral hip, 95 cm3 to the left upper lateral
thigh, and 95 cm3 to the right upper lateral thighs (Figs. 26
and 27). Two years and 4 months after the corrective proce-
dure, the indentation in the right and left iliac crest areas and
the left lateral hip and upper thighs was improved as seen in
the posterior and lateral views (Figs. 28 and 29).

Case 5 This 46-year-old woman developed postliposuction

contour irregularities in multiple sites including the buttocks,
Fig. 19 Persistent area of indentation and ridge in the right upper
quadrant lateral, medial thighs, knees, and the calves (Figs. 30,
396 K.N. Chang

Fig. 21 Preoperative photo: oblique view Fig. 23 Postoperative photo: oblique view

Fig. 22 Preoperative markings indicating indentation and transitional Fig. 24 Contour irregularities in the waist, lateral thighs, and lateral
zone (in red) and area of liposuction (in black) hip areas: posterior view
Lipofilling and Correction of Postliposuction Deformities 397

Fig. 25 Contour irregularities in the waist, lateral thighs, and lateral Fig. 27 Preoperative markings: left lateral view
hip areas: left lateral view

Fig. 26 Preoperative markings: posterior view Fig. 28 Twenty months after corrective surgery: posterior view
398 K.N. Chang

Fig. 29 Twenty months after corrective surgery: left lateral view Fig. 31 Multiple contour irregularities in buttock, lateral and medial
thigh, knees, and calves: posterior view

Fig. 30 Multiple contour irregularities in buttock, lateral and medial Fig. 32 Multiple contour irregularities in buttock, lateral and medial
thigh, knees, and calves: front view thigh, knees, and calves: lateral view
Lipofilling and Correction of Postliposuction Deformities
Fig. 33 Preoperative marking. Solid black color indicates areas for fat
grafting: front view
Fig. 34 Preoperative marking. Solid black color indicates areas for fat
grafting: posterior view
399
Fig. 35 Postoperative results: front view
31, and 32). Corrective surgery was performed in the supine
position first. Liposuction was performed in the upper thighs,
medial knees, and anterior superior knees. The fat was
injected into the right anterior thigh (23 cm3), right and left
mid-medial thighs (10 and 50 cm3), and abdomen (25 cm3).
The patient was next placed in prone position. Liposuction
was performed in the posterior thighs. The fat was injected in
the right and left posterior lateral thighs (90 and 100 cm3),
gluteal folds (40 and 20 cm3), and the calves (25 and 28 cm3).
The total amount of fat aspirated was 480 cm3. The total
amount fat transferred was approximately 420 cm3. The
recipient areas were pretunneled before the fat was injected
with a blunt-tipped cannula (Figs. 33 and 34). The postop-
erative results show improvement in the medial, lateral, and
posterior thighs and around the knees after 25 months
(Figs. 35, 36, and 37).
The patient returned to the operating room for addi-
tional improvement in the outer thighs, buttocks, knees,
and the legs. Liposuction was performed in the abdomen,
anterior and medial thighs, anterior superior knees, and
anterior proximal legs (Figs. 38 and 39). The arms, waist,
hips, and the right mid-posterior thighs were aspirated as
additional fat donor sites. Fat was injected into the abdo-
men (40 cm3), right anterior thigh (60 cm3), left anterior
thigh (30 cm3), left leg (20 cm3), right leg (10 cm3), right
and left lateral thighs, gluteal folds, and right posterior
400 K.N. Chang

Fig. 36 Postoperative results: posterior view Fig. 38 Preoperative markings of second corrective procedure: front view

Fig. 39 Preoperative markings of second corrective procedure: poste-

Fig. 37 Postoperative results: lateral view rior view
Lipofilling and Correction of Postliposuction Deformities 401

Fig. 40 Postoperative results after second procedure: front view Fig. 42 Postoperative results after second procedure: lateral view

upper thighs (400 cm3). A blunt cannula was used for fat
grafting at all the sites. At the right lateral thigh, upper
posterior thigh, and the gluteal fold, 16- and 18-gauge nee-
dles were used in addition to the blunt cannula. The post-
operative results 13 months after the second procedure
show that there is more fullness in the lateral and upper
posterior thighs. There is reversal of the soft tissue defi-
ciency and improvement in the sagging at the junction of
the buttocks and upper thighs (Figs. 40, 41, and 42).

Case 6 This 45-year-old woman had two previous liposuc-

tions in multiple body areas using tumescent technique
(Figs. 43 and 44). A total of 1,500 cm3 of aspirate was
removed from the abdomen. Prior to corrective surgery, she
was noted to have diffuse, irregular, circular, and oval inden-
tations of the lower abdomen and redundant skin of the upper
abdomen. The preoperative surgical markings identified
areas of protuberance in the right lower lateral abdomen,
suprapubic areas, supraumbilical area, and multiple areas of
indentation in the lower abdomen (Fig. 45). Areas of protu-
berance were infiltrated with 0.25 % lidocaine with
1:800,000 epi.
An internal ultrasound device was used to create space
for fat grafting in densely fibrotic subcutaneous tissue of
Fig. 41 Postoperative results after second procedure: posterior view
402
Fig. 43 Preoperative view with multiple irregular indentations: front view
Fig. 44 Preoperative view with multiple irregular indentations: oblique
view
the lower abdomen. The LySonix 2000 cannula at power
setting 2 was introduced into the subcutaneous space of
the lower abdomen caudal to the umbilicus after wetting
solution was infiltrated. This maneuver permitted break-
through of the scar which was confirmed by probing with
a blunt 2.4 mm cannula without suction. No fat was aspi-
rated during the application. Ultrasound application was
brief in duration. Fifteen cc of fat was transferred into the
lower abdomen. The deeper level was injected using a
K.N. Chang
Fig. 45 Preoperative markings with solid black indicating areas of fat
grafting
Fig. 46 Postoperative results: front view
blunt-tipped cannula. Sharp, circumscribed indentions
were injected with an 18-gauge needle at the superficial
(subdermal) levels. Postoperatively, the abdomen was cov-
ered with nonstick foam pad and elastic garment. Twenty
months postoperatively, some improvement in the contour
was observed (Figs. 46 and 47).
Lipofilling and Correction of Postliposuction Deformities
Fig. 47 Postoperative results: oblique view
Ultrasound is rarely used in corrective liposuction in
order to maximize the fat preservation. Its use may be sup-
plemented by the liposhifting technique and instrumenta-
tions referenced earlier.
5 Outcome and Complications
Reoperation for postliposuction contour irregularities is
expected to produce correction or improvement in most
patients when properly selected and performed on. The out-
come in 22 patients with 43 areas of postliposuction contour
irregularities was evaluated. Two areas were treated with
liposuction only. Nineteen areas were treated with com-
bined liposuction and fat grafting. Two areas were treated
with dermolipectomy. The outcome depended on the sever-
ity of the contour problems. The greater the contour irregu-
larities, the less likely it was to obtain a complete correction.
Ninety-five percent of the treated areas, including two der-
molipectomies, showed improvement or correction. Forty
percent of the patients required more than one operation.
Five percent (two areas) had minor overresection. There
were no serious complications as result of the treatment.
Dense subcutaneous scarring and diffuse multicentric defor-
mities limit the surgeon’s ability to obtain ideal result [5].
403
Fig. 48 Multiple contour irregularities around the thighs: anterior view
Several patients have been followed by the authors for
extended period of time over 15 years. The results of correc-
tive surgery and fat grafting persist in this group of patients
[12]. The following illustrates such a case.
A 44-year-old woman developed circular, linear, and
irregular-shaped depression in the medial, lateral, and ante-
rior thighs after liposuction (Figs. 48 and 49). She under-
went surgical correction consisting of additional liposuction
and fat grafting to indented areas. Fourteen hundred cc of
fat was aspirated. Two hundred cc was injected into various
sites of indentation. Fourteen months after the first correc-
tive procedure, additional liposuction was performed
around the thighs and the knees to balance out protuberant
areas not treated during the two previous procedures.
Postoperative results remained stable at 13 years and 4
months (Figs. 50 and 51).
404 K.N. Chang

Fig. 49 Multiple contour irregularities around the thighs: posterior view Fig. 51 Stable long-term results: posterior view

Pearls and Pitfalls

A potentially troublesome complication is overresec-

tion. This creates additional deformity in the patients.
The surgical techniques described in the preceding
sections incorporate features such as reduced vacuum
and reduced infiltration of wetting solution, which
are conducive to less aggressive fat removal and less
likelihood of overresection. Reduced vacuum results
in less fragmentation and alteration of the fat. Less
infiltration of wetting solution reduces the need to
concentrate the fat. It also reduces temporary swell-
ing and distortion during the surgery at the operative
sites.
Fat collection and injection can be time consuming,
especially when there are numerous sites requiring
repair. Adequate operative time should be allowed for
the operation.
Liposhifting is a method of internal rearrangement of
fat or “internal” fat grafting from adjacent area of relative
fat excess. In some cases, it can replace the need for autol-
ogous fat harvesting and transfer external to the body.
Fig. 50 Stable long-term results: front view
Lipofilling and Correction of Postliposuction Deformities
6 Informed Consent
An informed-consent form proposed by the American
Society of Plastic Surgery Fat Graft Task Force is included
below (http://links.lww.com/A1379) [13].
Informed Consent for Fat Transfer Procedures (Fat
Grafts and Fat Injections)
Instructions
This is an informed-consent document that has been pre-
pared to help inform you concerning fat transfer (fat
grafts or fat injection procedures), its risks, and alterna-
tive treatments.
It is important that you read this information carefully and
completely. Please initial each page, indicating that you
have read the page, and sign the consent for the procedure
or surgery as proposed by your plastic surgeon.
Introduction
A person’s own fat may be used to improve the appearance of
the body by moving it from an area where it is less needed
(usually the thighs or abdomen) to an area that has lost tissue
volume due to aging, trauma, surgery, birth defects, or other
causes. Typically, the transferred fat results in an increase in
volume of the body site being treated. Before the procedure,
the areas from where the fat is being removed may be
injected with a fluid to minimize bruising and discomfort.
The fat may be removed from the body by a narrow surgical
instrument (cannula) through a small incision or may be
excised (cut out) directly through a larger incision. In some
cases, the fat may be prepared in a specific way before being
replaced back in the body. This preparation may include
washing, filtering, and centrifugation (spinning) of the fat.
The fat is then placed into the desired area using either a
smaller cannula or needle, or it may be placed directly
through an incision. Since some of the fat that is transferred
does not maintain its volume over time, your surgeon may
inject more than is needed at the time to achieve the desired
end result. Over a few weeks, the amount of transferred fat
will decrease. At times, more fat may need to be transferred
to maintain the desired results. Fat transfer procedures may
be done using a local anesthetic, sedation, or general anes-
thesia depending on the extent of the procedure.
Alternative treatments
Alternative forms of nonsurgical and surgical management
consist of injections of man-made substances to improve
tissue volume (such as hyaluronic acid, polylactic acid,
etc.), use of man-made implants, or other surgical proce-
dures that transfer fat from the body (flaps).
Risks and potential complications are associated with alter-
native forms of treatment.
405
Risks of Fat transfer procedures
Every procedure involves a certain amount of risk, and it is
important that you understand the risks involved. An indi-
vidual’s choice to undergo a procedure is based on the
comparison of the risk to its potential benefit. Although
the majority of patients do not experience these complica-
tions, you should discuss each of them with your plastic
surgeon to make sure you understand the risks, potential
complications, and consequences of the procedure.
Bleeding. It is possible, though unusual, to experience a
bleeding episode during or after this procedure. Should
bleeding occur, it may require emergency treatment to
drain accumulated blood (hematoma). Do not take any
blood thinning medications, aspirin, or nonsteroidal anti-
inflammatory medications (acetaminophen is acceptable)
for 10 days before the procedure, as these may contribute
to a greater risk of bleeding or significant bruising. Tell
your surgeon if you are on any of these medications
before stopping them.
Seroma. Although unlikely, a collection of fluid may appear
at the site where the fat was removed. This is usually
treated by draining the fluid with a needle.
Infection. Infection is unusual after this procedure. Should
an infection occur, additional treatment including antibi-
otics or surgery may be necessary.
Scarring. All invasive procedures leave scars, some more visible
than others. Although good wound healing after a procedure
is expected, abnormal scars may occur both within the skin
and in the deeper tissues. Scars may be unattractive and of
different color than the surrounding skin. There is the possi-
bility of visible marks from sutures used to close the wound.
Scars may also limit motion and function. Additional treat-
ments including surgery may be needed to treat scarring.
Risks of Fat transfer procedures, continued
Change in appearance. Typically, the transferred fat loses
some of its volume over time and then becomes stable. It
is possible that more treatments may be needed to main-
tain the desired volume of the transferred fat and resulting
appearance. Less commonly, if you experience significant
weight gain, the transferred fat may increase in volume
and cause an undesirable appearance. It is important to
understand that more than one treatment may be needed
and therefore to discuss with your surgeon the costs asso-
ciated of repeat treatments.
Firmness and lumpiness. While most transferred fat results
in a natural feel, it is possible that some or all of the fat
may become firm, hard, or lumpy. If some of the fat does
not survive the transfer, it may result in fat necrosis (death
of transferred fat tissue), causing firmness and discomfort
or pain. Cysts may also form at the site of the transferred
fat. Surgery may be required to improve such conditions.
Asymmetry. Symmetrical body appearance may not result
from a fat transfer procedure. Factors such as skin tone,
406
fatty deposits, bony prominence, and muscle tone may
contribute to normal asymmetry in body features.
Long-term effects. Subsequent changes in the shape or appear-
ance of the area where the fat was removed or placed may
occur as the result of aging, weight loss or gain, or other
circumstances not related to the fat transfer procedure.
Pain. Chronic pain may occur rarely after fat removal or
transfer.
Tissue loss. In rare cases, the transferred fat may cause the
skin over the treated area to be injured resulting in loss of
the skin and surrounding tissue. This may leave scars and
disfigurement and require surgery for treatment.
Fat transfer to breasts. Fat transfer has been used to improve
the appearance of breasts reconstructed after cancer treat-
ment, to improve the appearance of breast deformities, and
to enlarge breasts for cosmetic purposes. While there is
limited information regarding the long-term implications
of such procedures, there are some potential concerns
especially with regard to breast cancer detection. Since the
transferred fat may become firm and cause lumps, it may
be necessary to have radiological studies (mammogram,
ultrasound, or MRI) performed to be sure these lumps are
not due to cancer. It is also possible that the firmness may
make it more difficult for you or your doctor to examine
the breasts. It is also possible that a biopsy may be needed
if there is concern about any abnormal findings in your
breasts. However, there is no reason to believe that fat
transfer procedures may cause breast cancer.
Damage to deeper structures. Deeper structures such as
nerves, blood vessels, or muscles may be damaged during
the course of this procedure. The potential for this to
occur varies according to where on the body the proce-
dure is being performed. Injury to deeper structures may
be temporary or permanent.
Unsatisfactory result. There is the possibility of an unsatis-
factory result from the procedure, resulting in unaccept-
able visible deformities, loss of function, wound
disruption, skin death, or loss of sensation. You may be
disappointed with the results of the procedure.
Allergic reactions. In rare cases, local allergies to tape, suture
material, or topical preparations have been reported.
Systemic reactions, which are more serious, may result
from drugs used during the procedure or prescription medi-
cines. Allergic reactions may require additional treatment.
Surgical anesthesia. Both local and general anesthesia involve
risk. There is the possibility of complications, injury, and
even death from all forms of surgical anesthesia or sedation.
Risks of Fat transfer procedures, continued
Serious complications. Although serious complications have
been reported to be associated with fat transfer procedures,
K.N. Chang
these are very rare. Such conditions include, but are not lim-
ited to, Fat embolism (a piece of fat may find its way into
the bloodstream and result in a serious or life-threatening
condition), stroke, meningitis (inflammation of the brain),
serious infection, blindness or loss of vision, or death.
Blood clots. Blood clots in the veins of the arms, legs, or
pelvis may result from fat transfer if it is done as a surgi-
cal procedure. These clots may cause problems with the
veins or may break off and flow to the lungs where they
may cause serious breathing problems.
Pulmonary complications
Pulmonary (lung and breathing) complications may occur
from both blood clots (pulmonary emboli) and partial col-
lapse of the lungs after general anesthesia. Should either
of these complications occur, you may require hospital-
ization and additional treatment. Pulmonary emboli can
be life-threatening or fatal in some circumstances. Fat
embolism syndrome occurs when fat droplets are trapped
in the lungs. This is a very rare and possibly fatal compli-
cation of fat transfer procedures.
Additional surgery necessary
In some situations, it may not be possible to achieve optimal
results with a single procedure. Multiple procedures may
be necessary. Should complications occur, surgery or
other treatments may be necessary. Even though risks and
complications occur infrequently, the risks cited above
are the ones that are particularly associated with fat trans-
fer procedures. Other complications and risks can occur
but are even more uncommon. The practice of medicine
and surgery is not an exact science. Although good results
are expected, there cannot be any guarantee or warranty
expressed or implied on the results that may be obtained.
Financial responsibilities
The cost of the procedure involves several charges for the
services provided. The total includes fees charged by your
doctor, the cost of surgical supplies, laboratory tests, and
possible hospital charges, depending on where the sur-
gery is performed. Depending on whether the cost of the
procedure is covered by an insurance plan, you will be
responsible for necessary copayments, deductibles, and
charges not covered. Additional costs may occur should
complications develop from the procedure. Secondary
surgery or hospital day surgery charges involved with
revisionary surgery would also be your responsibility.
Disclaimer
Informed-consent documents are used to communicate infor-
mation about the proposed treatment of a disease or condi-
tion along with disclosure of risks and alternative forms of
Lipofilling and Correction of Postliposuction Deformities 407

treatment(s). The informed-consent process attempts to
define principles of risk disclosure that should generally
meet the needs of most patients in most circumstances.
However, informed-consent documents should not be con-
sidered all inclusive in defining other methods of care and
risks encountered. Your plastic surgeon may provide you
with additional or different information that is based on
all the facts in your particular case and the state of medi-
cal knowledge.
Informed-consent documents are not intended to define or serve
as the standard of medical care. Standards of medical care
are determined on the basis of all the facts involved in an
individual case and are subject to change as scientific knowl-
edge and technology advance and as practice patterns evolve.
It is important that you read the above information care-
fully and have all of your questions answered before
signing the consent on the next page.

CONSENT FOR SURGERY, PROCEDURE or TREATMENT

1. -I hereby authorize Dr. ___________________________and such assistants as may be

selected to perform the following procedure or treatment:

Fat transfer including fat injections and fat grafts

I have received the following information sheet:

INFORMED-CONSENT FAT TRANSFER PROCEDURES

2. -I recognize that during the course of the operation and medical treatment or anesthesia,
unforeseen conditions may necessitate different procedures than those above. I therefore
authorize the above physician and assistants or designees to perform such other procedures
that are in the exercise of his or her professional judgment necessary and desirable. The
authority granted under this paragraph shall include all conditions that require treatment and
are not known to my physician at the time the procedure is begun.
3. -I consent to the administration of such anesthetics considered necessary or advisable. I
understand that all forms of anesthesia involve risk and the possibility of complications, injury,
and sometimes death.
4. -I acknowledge that no guarantee has been given by anyone as to the results that may be
obtained.
5. -I consent to the photographing or televising of the operation(s) or procedure(s) to be
performed, including appropriate portions of my body, for medical, scientific or educational
purposes, provided my identity is not revealed by the pictures.
6. -For purposes of advancing medical education, I consent to the admittance of observers
to the operating room.
7. -I consent to the disposal of any tissue, medical devices or body parts which may be
removed.
8. -I authorize the release of my Social Security number to appropriate agencies for legal
reporting and medical-device registration, if applicable.

9. -It has been explained to me in a way that i understand:

a)-The above treatment or procedure to be undertaken
b)-There may be alternative procedures or methods of treatment
c)-There are risks to the procedure or treatment proposed

I consent to the treatment or procedure and the above listed items (1-9).
I am satisfied with the explanation.

___________________________________________________________________________

Patient or Person Authorized to Sign for Patient

Date __________________________ Witness

__________________________________________
408
Acknowledgment Figures 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41,
42, 43, 44, 45, 46, 47, 48, 49, 50, and 51 are from Chang KN. Reoperative
Liposuction. In: Grotting JC (ed). Reoperative Aesthetic and
Reconstructive Plastic Surgery. 2nd Edition. St Louis: Quality Medical
Publishing, Inc. pp. 1601–1634, 2007.
Bibliography
1. Chang KN (2004) The use of intraoperative grid-pattern markings
in lipoplasty. Plast Reconstr Surg 114:1292–1297
2. Barton F, Markman B (1987) Anatomy of the subcutaneous tissue
of the trunk and lower extremity. Plast Reconstr Surg 80:248–254
3. Lockwood TE (1991) Superficial fascial system (SFS) of the trunk
and extremities: a new concept. Plast Reconstr Surg
87:1009–1018
4. Rohrick RJ, Smith P, Marcantonio DR, Kenkel JM (2001) The
zones of adherence: role in minimizing and preventing contour
deformities in liposuction. Plast Reconstr Surg 107:1562–1569
K.N. Chang
5. Chang KN (1994) Surgical correction of postliposuction contour
irregularities. Plast Reconstr Surg 94:126–136
6. Fodor PB (2002) Secondary lipoplasty. Aesthet Surg J 22:337–348
7. Coleman SR (2005) Structural fat grafting. In: Nahai F (ed) The Art
of aesthetic surgery: principles & techniques. Quality Medical
Publishing, St Louis
8. Chang KN (2007) Reoperative liposuction. In: Grotting JC (ed)
Reoperative aesthetic and reconstructive plastic surgery. Quality
Medical Publishing, St Louis
9. Saylan Z (2001) Liposhifting instead of lipofilling: treatment of
postlipoplasty irregularities. Aesthetic Plast Surg 21:137–141
10. Wall S (2009) Panel presentation- liposuction 20 years later: preci-
sion in shaping. Preventing and correction of countour irregulari-
ties, American Society for Aesthetic Plastic Surgery Meeting
11. Wall S (2010) SAFE circumferential liposuction with abdomino-
plasty. Clin Plast Surg 37:485–501
12. Chang KN (2002) Long-term results of surgical correction of
postliposuction contour irregularities. Plast Reconstr Surg
109:2141–2145
13. Gutowski KO, ASPS Fat Graft Task Force (2009) Current applica-
tion and safety of autologous fat grafts: a report of the ASPS Fat
Graft task force. Plast Reconstr Surg 124:272–280
 Plastic Surgery in Massive Weight Loss
Patients
Dennis J. Hurwitz and Siamak Agha-Mohammadi
1 Introduction
There are increasing numbers of men and women seeking
extensive body contouring surgery after massive weight loss
(MWL). For MWL patients, there were more than 68,000
body contouring procedures performed in 2006, spawning
subspecialty interest [1]. Since the senior author Hurwitz
joined the University of Pittsburgh Bariatric Surgery team in
1998, he has treated a steady stream of over 300 MWL
patients. With new techniques and technology, total body lift
(TBL) evolved, as a comprehensive aesthetic approach to
treat deformities after MWL [2]. In 2005 coauthor Agha
Mohammadi joined the Hurwitz Center for Plastic Surgery,
and together we have embraced the vast yet unique challenge
facing each patient. Following our report of the first 5 years
[3], we have improved patient preparation, increased safety,
designed new techniques, and learned from others.
Obesity is a leading health issue in the Western society. It
is an epidemic, causing about 300,000 deaths per year in the
United States [4, 5]. A report by the Centers for Disease
Control and Prevention confirms that poor diet and physical
inactivity will likely become the leading cause of prevent-
able, premature death in the United States unless obesity is
reversed [6]. According to the National Health and Nutrition
Examination Survey (NHANES) data from 2003 to 2004,
66.3 % of American adults were classified as either over-
weight or obese, 32.2 % were obese, and 4.8 % were mor-
bidly obese [7]. Furthermore, the trend towards ubiquitous
obesity is ominous [8]. The correlating body mass indices
(BMI – kg/m2) used to define overweight, obesity, and mor-
bid obesity are 25.0–29.9, 30.0–39.9, and over 40.0, respec-
tively [9].
D.J. Hurwitz, MD, FACS (*)
S. Agha-Mohammadi, BSc, MB BChir, PhD, FACS
Department of Plastic Surgery, University of Pittsburgh
Medical School, Pittsburgh, PA, USA
e-mail: drhurwitz@hurwitzcenter.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_29
Of all the available methods, weight loss surgery (WLS)
is the most effective long-term treatment for obesity by its
ability to provide sustained weight loss as well as ameliora-
tion of obesity-related comorbidities [10, 11]. Thus, the
number of bariatric operations has risen each year with over
200,000 procedures performed in 2007 alone [12]. The cur-
rent core of WLS is drastic reduction of food consumption
by means of restrictive, malabsorptive, or a combination of
both interventions [13].
The two most common bariatric operations are the laparo-
scopic adjustable gastric banding (LAGB) and the Roux-en-Y
gastric bypass (RYGBP) [10, 14, 15]. LAGB is a restrictive
procedure, in which a small gastric pouch with a small outlet
is created, resulting in early and prolonged satiety. Since the
normal absorptive surface is left intact, specific nutrient defi-
ciencies are rare. The RYGBP procedure involves both
restrictive and malabsorptive components [10, 16]. The stom-
ach size is decreased to less than 30 ml proximal gastric
pouch with a 75–150 cm Roux limb connected as an entero-
enterostomy to the jejunum, 30–50 cm from the ligament of
Treitz. By reducing the body of the stomach, the patient loses
storage capacity, as well as hydrochloric (HCl) acid, pepsino-
gen, intrinsic factor, gastrin, and mucus. HCl coagulates pro-
tein and along with pepsinogen initiates the digestive process
for proteins. HCl is also important in iron absorption. In addi-
tion, elimination of the body of stomach severely restricts the
process of food grinding which is important in releasing vita-
mins and minerals. By forming the Roux-en-Y anastomosis,
the coordination between gastric emptying and pancreatic
enzymes release is lost, leading to maldigestion and malab-
sorption. Some older procedures that are less commonly per-
formed include vertical banded gastroplasty (VBG) and
biliopancreatic diversion (BPD) and BPD with duodenal
switch (BPDDS) [17, 18]. Adverse psychological conditions
and nutritional deficiencies are significantly higher for these
radical malabsorptive procedures [19, 20].
WLS produces weight loss within a year after surgery,
which is 3–4 times superior to what can be achieved with
nonsurgical weight management programs [10]. More
409
410
importantly, patients who lose weight with WLS are more
likely to maintain most of the lost weight and sustain their
reduced weight for many years [10]. Weight loss after WLS
is not only influenced by the selected surgical technique and
its inherent parameters but also by the gender, age, ethnicity,
and compliance with dietary and physical activity recom-
mendations. Weight loss starts immediately after RYGB and
continues at a relatively fast pace for 12–18 months [21]. The
average 300 lb patient experienced an average absolute
weight loss of 125 lb or a relative weight loss of 40 % of the
initial weight (75–80 % loss of excess weight) at 1 year.
Many patients began to gain weight after the 2nd year and on
average gained about 25 lb by their fifth postoperative year.
After that, the weight loss remains relatively stable from the
5th to the 14th year [21].
MWL leads to redundant and lax skin. A decade ago,
body contouring surgery lacked the techniques and coordina-
tion needed to match the extensiveness of the deformity, not
unlike the craniofacial deformity challenge 20 years before.
The MWL deformity spawned new lengthy procedures with
longer scars not accepted by other cosmetic patients. Areas
of the body virtually ignored by plastic surgeons, such as the
mid-torso, axilla, buttocks, and posterior thigh, were now
being reshaped. On the breasts and buttocks, tissue excess
was being reformatted into flaps for augmentation and sus-
pension. The vastness of the deformity has led to innovative
and comprehensive grouping of operations [2, 22]. As most
patients sustain numerous operative sessions each with
months of recovery, we have explored combining as many
procedures as possible during a given operative session.
Plastic surgery patients tolerate long operations without
adverse systemic effects, due to a relatively low systemic
inflammatory response to skin surgery. Since no single inci-
sion is open for more than several hours, serious wound
infections due to prolonged exposure are rare. Advances in
preoperative preparation, autologous blood transfusions,
intraoperative organization, and technique have reduced the
risk. In 2002, Hurwitz created TBL surgery, which is the
coordinated comprehensive and artistic reshaping of the
body in as few stages as safely possible [2]. Four criteria
empirically established for a one stage were (1) medically
and psychologically fit, (2) young (under 50 years age), (3)
not obese, and (4) highly motivated. Ideally the patient is a
nutrition and exercise enthusiast. Highly motivated means a
one-stage operation is such a priority; he or she is willing to
accept an increased risk of complications and revision sur-
gery. Such was the case of a traveling 41-year-old certified
public accountant, with a BMI of 27 after losing 160 lb, con-
cerned about the sagging skin of her arms through her torso
to her thighs. She not only had a complication-free 10 h
operation but also returned to work within 3 weeks (Fig. 1).
Six years later she underwent a limited scar facelift (Fig. 2).
While the four criteria appear to have stood the test of the
D.J. Hurwitz and S. Agha-Mohammadi
past 8 years, they have not yet been subjected to scientific
validation. There is some elasticity in the criteria as young
patients may be obese and super fit patients may be older, but
in general our obese patients are staged. Figure 3 is a 46-year-
old patient of Dr. Agha Mohammadi, with a BMI of 31, who
completed three-stage TBL surgery and reveals her 9-month
result (Fig. 3).
2 Anatomy
An hourglass narrowing between flared costal margins and
broader hips characterizes the sensual female physique. The
soft skin of the arm conforms to the underlying muscles.
With the left arm abducted about 45°, sweeping S shape con-
tours from the proximal arm through the axilla, curving
around the lateral breast and then along the descended lateral
portion of the inframammary fold (IMF). There is a mirror S
curve on the right side. Rounded inferiorly and tapered supe-
riorly, buoyant breasts end abruptly along the sternal margin
and taper as the tails of Spence to the axilla. The inferior
folds form the breasts’ most distinct demarcation with the
chest, followed by the gentler bordering with the closely
adherent skin of the lateral chest. The adherent upper abdom-
inal skin reveals underlying costal margin and sometimes the
lower ribs. The thicker skin of the back subtly exposes the
inferolateral scapula and stretches over the posterior ribs
prior to dropping into the flanks and then ascending over the
prominence of the pelvic rim. There are no rolls or sagging
tissue. Paramedian vertical muscular rolls surround the sinu-
ous and gradually depressed spinal curve. The buttocks and
hips form the largest trunk convexity followed by tapering to
and beyond the lateral trochanters of the thighs, ending into
the flat plane along the distal thigh. While there are some
variations in aesthetic buttock shape, the most pleasing
waist-to-hip ratio is 0.7:1.0. The posteromedial thigh is
demarcated from the buttock with a well-defined fold, which
fades in the midline. Anteriorly, the thighs are smooth and
conform to the mass of the underlying muscles. The upper
inner thighs are soft and flat and end as a gradual fullness of
the medial thighs. These idealized features are affected by
skeletal form, muscular development, organ size, adiposity,
pregnancy, hormones, and skin quality. The plastic surgeon
factors in these features when analyzing the anatomy and
creating an optimal treatment plan and appropriate
expectations.
MWL in the obese leaves a displeasing spectrum of
changes as determined by genetics, age, highest and current
weight, weight fluctuations, environmental insults, and hor-
mones. The pathophysiology of skin laxity after weight loss
is poorly understood and irreversible. The deformity starts
with the altered structure of skin and subcutaneous tissue
with massive weight gain. Hypertrophy of the existing fat
Plastic Surgery in Massive Weight Loss Patients
Fig. 1 (a–f) These are multiple views of a normal-sized, 42-year-old
MWL patient with BMI of 27 before and years after total body lift sur-
gery by Hurwitz. The photos show her presenting deformity (a, e and f
left), her deformity with markings for her TBL (a right, c and d left), the
3-year result just before excision of extra skin from her arms and partial
subpectoral 250 cc. gel implant augmentation (b left), and then three
more years later (b–f right). Her deformity and new shape after TBL
surgery are described under section (b) Anatomy in the text. Marking
TBL surgery like hers is described under sections (c) and (d) in the text.
Her recent limited facelift is seen in Fig. 2. The long limb of the L bra-
chioplasty excision encompasses the lower half of the medial arm. The
411
short limb across the axilla is narrower and shorter than we now draw
it; therefore, she has inadequate reduction of her hyperaxilla. The Wise
skin pattern skin excision for mastopexy extends slightly inferior onto
the lower chest and far lateral to the breasts to encompass the deepithe-
lialized spiral flap for reshaping. There is a broad skin excision of the
lower abdomen and torso. There is a wide crescent excision of the
medial thighs. In 2003, we would not accept the long vertical scars of a
medial thighplasty, but through the years, the looseness of her mid- to
distal thighs has become her only concern. While her suture-stabilized
IMF has held, the breast implant augmentation is unattractively expand-
ing her lower pole at the loss of some superior pole fullness
412 D.J. Hurwitz and S. Agha-Mohammadi

Fig. 1 (continued)
c

d
Plastic Surgery in Massive Weight Loss Patients 413

Fig. 1 (continued)
e

f
414
Fig. 2 These are before (right)
and 3 months after an extended
MACS (minimal access cranial
suspension) facelift (left) of a
48-year-old woman presented in
Fig. 1. The submental and lower
face laxity has been corrected
with new fullness of her cheeks,
softening of the eyelid cheek
junction, and definition of her
jaw line. The overall effect is
subtle, youthful, and natural
cells beyond the limits of cellular expansion leads to cell
death through apoptosis and release of triglycerides and then
inflammation. Nearby dormant pluripotent preadipocytes are
stimulated into fat containing mature adipose cells for a cel-
lular hyperplasia. Hypertrophy of the adipose tissue results
in three-dimensional stretching of the interconnecting
collagen of Scarpa’s fascia and fractures of the dermis.
Consequently, zones of adherence and demarcations become
loose and the skin develops striae. With cycles of weight gain
and loss, expansion of the soft tissues of the body adversely
affects the skin. The negative caloric balance of MWL leads
to a reduction in the adiposity throughout the body and
thereby a deflation of the tissue and sagging. Caloric
deficiency also induces irreversible laxity through metabo-
lizing structural protein such as collagen and elastin.
Regardless of the mechanism, MWL causes dramatic
deformity. Characteristically the face appears aged with sag-
ging of the cheeks, descended jowls, and hanging upper neck
skin, and fat. The connective tissue attachments of the poste-
rior arm elongate with sagging of the posterior border and a
broad attachment to the chest, giving a bat-wing appearance.
The axilla becomes loose and deep with descent of the pos-
terior axillary fold inferolaterally, leading to what we call
hyperaxilla, which Strauch refers to an axillary roll [23, 24].
Usually there is some residual fatty tissue excess that hangs
from the posterior portion of the arm; however, the entire
arm may be oversized. We find that the torso exhibits from
one to three rings of hanging skin. Invariably one ring con-
tains the hanging pannus of the lower abdomen. The pannus
D.J. Hurwitz and S. Agha-Mohammadi
often extends over the pubic and groin region. There may be
one large apron of skin, but more often there is a transverse
roll on the level of the umbilicus caused by an adherence
through thinned subcutaneous tissue of deep dermis to mus-
cular fascia. Several more folds of skin may lie across the
mid- to lower back. The mid-torso forms rolls that extend
from the sternum to the vertebral column. The buttocks
deflate and sag with low back skin descending far the pelvic
rim. The mons pubis may overhang the adherent labia majora
with both vertical and transverse excess. The thigh sags
greatest at the trochanters and medially.
The breasts deflate, flatten, and sag, resulting in poor pro-
jection and glandular ptosis as well as nipple ptosis. The
changes in the breasts are unpredictable, because they are
composed of both gland (influenced by hormones and lacta-
tion) and fat tissue, with a lattice of connective tissue and skin
covering. The magnitude of breast deformity depends on the
ratio of parenchyma to fat, the quality of the connective tissue
lattice, the original weight and shape, the girth of the sur-
rounding abdomen and back, the zones of fascial adherence,
and post-lactation atrophy. The breast deflation is more pro-
nounced superior and lateral as the footprint and the IMF
descends inferolaterally. The breasts are shortened by the loss
of breast tail of Spence and the lateral thoracic demarcation.
The upper chest laxity hangs loosely as mid-torso cascad-
ing rolls, at times overwhelming the breasts. The IMF under
each breast is pulled down by the weight of the hanging
abdominal pannus with greater effect laterally due to less
firm adherences. This pull deforms the shape and form of the
Plastic Surgery in Massive Weight Loss Patients
Fig. 3 (a–d) These are multiple views of an overweight nearly obese,
46-year-old MWL patient with BMI of 31 through laparoscopic
RYGBS with her presenting deformity before (left) and 9 months after
the last of three-stage TBL surgery (right) by Agha-Mohammadi.
Refer to second (b) Anatomy in the text. The first stage was a lower
body lift with circumferential abdominoplasty, buttock reshaping, and
415
spiral thigh lift. The second stage included liposuction of her thighs
and medial vertical thighplasty. During her final stage, she had L
brachioplasty, bra line upper body lift, and dermal suspension breast
lift. The scars of UBL do not cross either the anterior or posterior
midline. LBL reduces the hip and upper buttock roll, while UBL
effaces the mid-torso rolls and leaves a narrowed waist
416 D.J. Hurwitz and S. Agha-Mohammadi

Fig. 3 (continued)
c

d
Plastic Surgery in Massive Weight Loss Patients
IMF, resulting in displacement of the breasts on the chest
region. These changes further deform the breast/chest demar-
cation and result in a boxy contour. The vertical upper body
laxity often presents as hanging tissue that drapes from the
sternum anteriorly to the vertebral column posteriorly with
up to five back rolls [24]. We prefer to describe these changes
as those of the upper torso, mid-torso, and lower torso. The
upper torso rolls include the rare axillary roll and the more
frequent breast roll. The latter extends from the breast tail
over the chest towards the vertebral column above the
IMF. The mid-torso laxity can present as one or two rolls that
are located between the IMF and umbilicus. The lower back
roll, also known as the hip roll, spans horizontally over the
lower back and upper buttock at the level of the waist and
continues as the abdominal pannus anteriorly. About 20 % of
our MWL patients exhibit minimal to no back laxity,
whereas, in the remaining 80 %, mid-torso rolls are the most
consistently noted folds.
3 Surgical Techniques
Body contouring surgery of the MWL patient is compressed
into ten principles [2].
Principle 1 is that each deformity needs to be described
and analyzed in the context of the entire presentation, similar
to the analysis of craniofacial malformation. Encourage
patients to be fully evaluated and not focused on one area.
Principle 2 is to correct the vertical excess by excising
excess skin transversely, to leave the torso scars within bra line
and panties. For men that means a band line correction of their
gynecomastia with a circumferential lower body lift. Broad
removal of two bands of torso skin corrects the vertical excess
and to a limited extent reduces the transverse excess.
Unacceptable transverse excess can be removed vertically, usu-
ally through the anterior midline as in a Fleur-de-Lis abdomi-
noplasty or less commonly through midlateral-long lateral
thoracoplasties. A Fleur-de-Lis excision is recommended in
most patients who already have a long midline abdominal scar
or who want the least amount of surgery for the greatest
improvement for the lower torso. Lateral torsoplasties are per-
formed either primarily or secondarily when dramatic improve-
ment in waistline concavity is desired (Fig. 4).
Principle 3 is to convert skin and subcutaneous tissue
excisions to dermal-adipose-fascial flaps for hip, buttock, or
breast augmentation. The persistent exuberant vascularity of
the previously obese subcutaneous tissue provides adequate
blood supply as long as perforating vessels are preserved.
These healthy tissues add convexity and fill transverse skin
laxity. MWL patients express aversion to silicone implants
for the breasts or buttocks and prefer to accept the immediate
risks of flap necrosis than to add implants and have progres-
sive ptosis.
417
Principle 4 is to plan the incisions and excisions reliably
and favorably preoperatively using multiple patient posi-
tions. One learns where tissue can be lifted and where it is
firmly adherent. Surgeons learn to use pinch, pull, and gath-
ering techniques to definitively mark excisions, needing little
adjustment during the operation. These skills facilitate expe-
ditious team surgery. We usually fully mark the patient the
evening before surgery. We are no longer rushed, and the
patient has time to understand the operation and resulting
scars. Hence, the better informed patient enters the operating
room confident in the surgical plan and no longer chilled by
a half hour or more of preoperative exposure. If you do have
to mark immediately preoperatively, they will spend 15 min
or so under warm forced hot air prior to the induction of
anesthesia to raise skin temperature.
Circumferential surgery demands an operative plan that
includes multiple patient positions. We prefer prone fol-
lowed by the supine, which facilitates symmetry, and
simultaneous operations. While in the prone position the
legs are abducted on articulating arm boards in order to
close the lateral portion of the lower body lift under maxi-
mal skin excision with the least tension. When the closure
is complete and the legs are returned to their anatomical
adducted position, tight vertical tension bands across the
greater trochanter are evident. Guard against over-excision,
which leads to wound separation and delayed healing. The
patient is wrapped in a sterile gown and easily turned
supine onto an adjacent stretcher and then slid back onto
the operating room table. When supine the thighs are gently
frog legged to maximize upper thigh skin tension during
the abdominoplasty closure. The arms are simply placed on
arm boards for lipoplasty, medial skin excision, and
closure.
While removal of hanging skin is essential, Principle 5
demands focusing on the contour and tensions left behind.
The goal is to create idealized gender-specific contours. That
approach requires selective retention of subcutaneous fat or
localized liposuction. High-tension closure extends the
impact of lift but will flatten the contour across the closure.
Wound closure is performed as expeditiously as possible.
After years of depending on large-sized braided permanent
interrupted subcutaneous sutures, we changed to running
absorbable sutures. The large knots and permanency of the
former suture material may lead to a prolonged series of
suture abscesses. Despite the admonition of Lockwood to
use permanent braided sutures [25], we have found that
absorbable braided sutures last long enough for definitive
healing. Nevertheless, no closure technique of the subcuta-
neous tissue is able to forestall the occasional elongation
with thinning and depressed distraction beneath the healed
skin scar. That phenomenon, which is akin to the central
tinning of pulled taffy, is related to the nature of the tissues
and the nutritional status of the patient.
418 D.J. Hurwitz and S. Agha-Mohammadi

Fig. 4 (a, b) These frontal and right lateral views are before and 1 narrowed her waist. Securing the lateral IMF prevented sagging of her
year after abdominoplasty with lateral torsoplasty and bilateral breast breasts. Retention of most all hip fat accentuated the feminine figure.
augmentation with partial subpectoral 425 cc. saline-filled implant. The central pubic excision improved the ptosis but left an
The wide and long lateral thoracic excisions tighten the torso and unacceptable dome shape
Plastic Surgery in Massive Weight Loss Patients
Over the past 2 years, Hurwitz has preferred a two-
layered Quill SRS (Angiotech Pharmaceuticals, Vancouver,
Canada). The deep subcutaneous layer is closed with long-
lasting barbed PDO double-armed large-taped needle
sutures. The numerous microscopically closed barbs pro-
vide a self-retaining, Velcro-like approximation of tissues
that allow for precise synching and eversion of tissue edges.
There is no time-consuming knot tying or troublesome pal-
pable or spitting knots. It is important to place each bite of
the running suture precisely. The larger sizes, such as #2
PDO, are used for closure of the lower body lift, placed
several millimeters deep to the dermis, and completed with
a J-like return at the end and exits through the wound open-
ing. A vertical closure, starting at the middle and synching
after every other throw, is ideal for thicker adipose. After
the first synch, closure may rapidly continue with a sepa-
rate operator at each end of the thread. The spiral-like pat-
tern of the broadly running suture appears to minimize
localized fat necrosis that may occur within a tightly tied
interrupted circular stitch. A weaving horizontal closure for
brachioplasty and vertical medial thighplasty is easy to
insert and dependably secure within tissues that tend to
have delicate subcutaneous fascia. There can be annoying
palpable subdermal sutures and suture exposure with local-
ized infection. At times that is due to using oversized suture
and to doubling back too much, causing tissue ischemia.
The second layer is a deep dermal running closure of 2–0 or
3–0 Monoderm, a rapidly absorbing clear barbed suture
(Angiotech Pharmaceuticals, Vancouver, Canada). Liberal
application of skin glues such an Endermil® (American
Surgical) approximates and seals the epidermis without
blistering as sometimes occurs with skin strips.
In order to minimize tissue trauma and postoperative
swelling, Principle 6 is the preservation of the dermis and
subcutaneous fascia with minimal use of electrocautery for
incisions and preservation of dense lymphatics along the
medial arm and thigh skin removals through radical excision
site liposuction (ESL). Preinjection with epinephrine con-
taining fluids allows for minimal blood loss and scalpel inci-
sions. Electrocautery is reserved for bleeders and
undermining. ESL is the near-complete liposuction removal
of fat in the medial arm and thigh sites to be excised for bra-
chioplasty and thighplasty.
Principle 7 is the gentle removal of fat for volume reduc-
tion and undermining of retained flaps. Hurwitz generally
uses advanced ultrasound and aspiration technology as pro-
vided by VASER® (Sound Surgical Technologies, Louisville,
Colorado). Fat is removed as dictated by the desired contour
change, as there is rarely vascular injury. There is no bleed-
ing and the vessels can later be seen intact during limited
dissection. For excessive adiposity with little skin laxity,
especially in the upper arms and thighs, liposuction is per-
formed in a preliminary stage.
419
Principle 8 is to perform minimal undermining of tissues
that will be closed under high tension. Very loose skinned
bodies need no undermining. For the heavier patients, lipo-
suction or special underminers that preserve cutaneous per-
forating vessels achieve further release of tissue. Combining
extensive direct undermining with liposuction may cause
distal flap necrosis.
Principle 9 is to use intra- and postoperatively all possi-
ble measures to maintain patient’s homeostasis and to retard
swelling, seroma, infection, and hematoma. The immediate
management addresses operative resuscitation, pain, and
fluid and blood management, which can all be accomplished
in cooperation with anesthesiologists and then on an experi-
enced hospital nursing floor. We rely on fluid balance, drain
outputs, vital signs, and periodic hemoglobin to direct fluids
and transfusion. Serum electrolytes and proteins are mea-
sured when indicated. Seromas have virtually disappeared
in our practice through preservation of lymphatics by exci-
sion site liposuction and the use of suction drains in the
trunk, especially where liposuction has been combined with
flaps. Invariably, there is retained tumescent fluid or early
inflammatory weeping of tissues after liposuction, which
may accumulate in the large undermined spaces of a con-
tiguous abdominoplasty, which can drain considerably for
the first few days after a combined liposuction with body
contouring excisions. No drains are used in thighplasty or
brachioplasty, as there is no dead space to drain and uniform
elastic garment compression suffices. If serum collects in
the extremities, seromas tend to be weeks after surgery, long
after drains would have been removed, and are probably due
to damage to lymphatics, which is minimized by ESL. In
fact, it is probable that negative pressure of suction drains
promotes openings of micro tears in the lymphatics, causing
lymphoceles.
We are impressed by the efficacy of strategic placement
of foam rubber and properly sized and fitted garments. The
reliable pressure and long-lasting elasticity of Marena®
(The Marena Group, Inc, Lawrenceville, GA, 30043) post-
operative antibacterial garments with ComfortWeave® fab-
ric have proven to be excellent investments in care and
patient satisfaction. Except when examining the wound clo-
sures, the elastic garment is left undisturbed for 1 week and
then removed during the nighttime for 1 week and sedentary
times for the next and retained until no longer appearing ben-
eficial. Generalized postoperative retention of tissue fluids
with greater amounts in the site of injury and areas of depen-
dency can seriously delay healing and diminish outcome
appearance. Patients are encouraged to continue their nutri-
tional supplement, taking two to three scoops a day, and to
limit their salt intake. Oral diuretics treat excessive edema
especially when manifest in the ankles, but overall we are not
impressed by their efficacy and concerned about inducing
electrolyte imbalance.
420
Persistent soft tissue swelling is uncomfortable, is
unsightly, delays healing, and at times mars the ultimate
results. To combat that problem, within days from surgery
patients are started on massage and deep oscillation therapy.
Hurwitz provides portable HIVAMAT® units for massage
and electrostatic oscillatory therapy throughout their oper-
ated areas twice daily. The surgical injury causes the entrap-
ment of accumulated metabolic waste in the interstitium. It
is trapped because the various components such as acids,
by-products from protein synthesis, protein solids, neu-
rotransmitters, and other cell wastes are either positively or
negatively charged particles or molecules. Dissimilar
charges attract each other. Like charges repel. Acids have a
positive polarity. Other waste molecules have negative
polarity. Positives and negatives attract each other and bind
to each other in the interstitial spaces in the connective tis-
sues. Over time, these molecules attract more and more dis-
similar charged particles until there is an impasse in the
interstitium. These groups of molecules become too large to
move freely into the lymphatic collectors. This phenomenon
causes a cessation of normal uptake of nutrients, and elimi-
nation of waste by the cells and an acid condition and swell-
ing occurs in the tissue. When HIVAMAT (HIstologically
VAriable MAnual Technique) therapy is introduced into the
tissues, the molecules are separated momentarily (like
charges repel; dissimilar charges attract). With the introduc-
tion of the electrostatic field in the patient’s tissues, these
tissues are attracted to the hands of the therapist, which
causes a “micro compressive” effect. This compressive
effect combined with the simultaneous separation of the
molecular particles (caused by the electromagnetic field and
the electrostatic field of the same polarity) allows them to
once again move freely into the lymphatic collectors and out
of the body. This is the only device that specifically focuses
on the microcirculatory system in the connective tissue
(www.hivamat200.com). The immediate reduction in swell-
ing is obvious and satisfying to our patients. There will be a
partial return of swelling after each treatment and so the
HIVAMAT is applied at home twice daily for 2–6 weeks,
until there is no longer an obvious response to the therapy.
Since most of our patients pay nominally for this treatment,
it is clear they are compliant and most are very pleased with
the results.
For persistent areas of induration of closures or localized
fat necrosis, Hurwitz’s staff twice a week provide superlumi-
nous diode (SLD) and low-level laser therapy (LLLT)
through MedX® (MedX Health, Mississauga, Ontario,
Canada) phototherapy system. There is immediate reduction
of swelling, induration, and pain with patient satisfaction.
The emitted photon of near infrared (785 nm and 870 nm)
and visible red (630 nm) penetrates the skin stimulating a
cascade of clinical benefits. The absorbed radiant energy
improves mitochondrial and cell membrane function to
D.J. Hurwitz and S. Agha-Mohammadi
reduce inflammation and accelerate wound healing (for more
information, visit www.medxhealth.com).
Principle 10 is to design efficiency and teamwork with a
conscientious effort towards effective leadership throughout
these lengthy operations. Establishing and maintaining com-
plex and productive operative teams are difficult, especially
in the private practice environment. There must be a steady
stream of patients to treat in order to recruit and maintain the
human resources. The lead surgeon must understand the
capabilities of each member of the team and motivate them to
perform at their highest level. While the leader takes on the
most difficult challenges, he must pleasantly accept frequent
interruptions to guide the other operative teams and adjust
personnel. He commands respect and benefits by the coopera-
tive hard work of his team. He should debrief key members of
the team as to individual and collective performances and
review the alternative approaches to the ones taken.
Having elucidated our principles for body contouring
after MWL, we present a sample of the operative sequencing
and preparation of the patient for TBL surgery [26]. While
surgical plans vary, usually the fundamental and most dis-
turbing features are on the lower trunk. As such, planning
begins with abdominoplasty, which continues around the
trunk superior to the hips and buttocks. If there is to be mini-
mal lifting of the lateral thighs and buttocks, then this cir-
cumferential removal is considered a belt lipectomy [27].
Our preference is to place the posterior excision along the
hips and buttocks to hide the scar under panties and exert the
greatest pull on the saddlebags and buttocks. Augmentation
of the buttocks with an adipose fascial flap of otherwise
excised upper buttock adipose is commonly placed in a
supragluteal muscle pocket. For the posterior thigh lift, a
crescent of skin and adipose tissue is removed between the
lower buttocks and upper posterior thigh. A full-thickness
cutaneous advancement of the posterior thigh is secured to
the ischial tuberosity to define the infragluteal fold and hide
the short transverse scar under the lower buttocks. As such,
the lower buttock is supported like the inferior pole of the
breast. The crescent excision continues anteriorly to meet the
upper medial thighplasty to complete the spiral thighplasty.
A vertical medial excision down to the knees is usually added
[28]. Hurwitz believes the tension vectors of a lower body
lift and vertical thighplasty are complementary. However, for
the tensely fat-filled thighs, a first stage liposuction will be
followed later with a vertical medial thighplasty. Likewise
aggressive undermining of the gluteal flap to accommodate
an upper buttock adipose fascial flap increases the risk for
suture necrosis and dehiscence of the lower body lift. For
that reason we now rarely combine lower body lift, fascial fat
augmentation with inferior gluteal fold, and posterior thigh
advancement.
The upper body lift (UBL) with breast and upper arm
reshaping is either performed immediately after the lower
Plastic Surgery in Massive Weight Loss Patients
body lift (LBL) and abdominoplasty or as a second stage
three or more months later. UBL is a near circumferential
removal of mid-torso skin, which only in the most severe
redundancy cases crosses the xiphoid/sternum or the poste-
rior spine. When there is adequate surrounding tissue, the
excess back and epigastric tissues in the form of lateral tho-
racic and epigastric flaps are harvested in continuity with the
central breast mount to augment and suspend the breast. In
women the surgical challenge is to raise the footprint of a
soft and flaccid breast while maximizing surrounding clo-
sure tension on the epigastrium and mid-back. The short
limb of L brachioplasty descends along the mid-lateral chest
by taking out excess skin without lateralizing the breasts,
creating a tail of the breast that smoothly transitions into the
rounded lateral breasts. Finally the axilla is reduced in size
and depth with a smaller and more natural-appearing
upper arm.
Combining multiple procedures in body contouring of
MWL patients was published first by Zook in 1975, and oth-
ers have periodically presented that concept [22, 29–31]. We
believe in team surgery, as it reduces operative time, but not
trauma. The use of the running barbed suture likewise sig-
nificantly reduces operative time. Team surgery assumes the
direction of a master surgeon over multiple simultaneous
operations. Detailed planning of sequence and assignment of
talent minimizes delays and maximizes productivity. A post-
op critique is valuable for learning.
There are a number of items to consider for the prepara-
tion of the MWL patient for comprehensive body contouring
surgery. The patient’s expectations must be matched to the
surgeon’s capabilities and that can be very difficult to deter-
mine due to the enormity of the project. The aesthetic result
may fall sort with residual skin laxity, unsightly scars, and
asymmetry. Minor wound healing problems and revision sur-
gery appear more likely after multiple operations, which
should be explained to the patient. A history of obesity and
its many associated comorbidities make medical and psycho-
logical clearance and proper management critical. Obesity is
associated with diabetes, high blood pressure, cardiovascular
disease, sleep apnea, cholelithiasis, depression, and arthritis.
MWL results in resolution or at least improvement of these
conditions, but inquiries need to be thorough and manage-
ment of residual medical and/or psychological disease needs
to be optimized.
Decisions also have to be made regarding replacing blood
loss, thrombophlebitis prophylaxis, and special beds for
postoperative positioning. Up to two units of autologous
blood may be banked preoperatively. Alternatively Hurwitz
has preferred using the bags of blood drawn during immedi-
ate preoperative normovolemic hemodilution. Since older
banked blood has considerable red cell crenation, which
potentiates intravenous thrombophlebitis, Hurwitz has sev-
eral units of blood removed by the anesthesiologist after the
421
induction of general anesthesia, while intravascular volume
is being replaced with saline. Diluted blood is lost during the
operation and thicker blood is returned at the termination of
the procedure. Additional prophylaxis for thrombophlebitis
relates to risk factors, such as obesity, age, prior phlebitis,
long operation, etc. [32]. Abdominoplasty is considered a
double risk factor. More than three factors necessitate preop-
erative Lovenox®; otherwise the low molecular weight hep-
arin is started 6 h after all operations that include an
abdominoplasty and is continued during the hospital stay
and stopped when ambulation is regular [33]. Patients with
lower body lifts and especially fascial flap augmentation are
placed in KCI flotation beds to reduce pressure on the suture
line and inhibit incision line breakdown. Proper timing of
surgery after the weight loss surgery relates to nutrition and
tissue laxity.
With up to 50 % of reported nutritional deficiencies occur-
ring within the 1st year of WLS, it is essential to pay atten-
tion to the patient’s nutritional status prior to body contouring
procedures. We schedule body contouring surgery only when
the patient’s weight has reached a plateau for several months.
We consider this period critical for replenishing patient’s
nutritional reserves. Beware of the 3–5 % of post-bariatric
patients that lose greater than 100 % of their excess weight,
or suffer multiple dietary restrictions or vomiting, as they are
likely to be malnourished.
Bariatric surgery reduces nutrient absorption often result-
ing in nutritional deficiencies of proteins, vitamins, and min-
erals that cause poor wound healing, anemia, and impaired
clotting mechanisms and reduce immune response. Many of
our patients are deficient in protein; vitamins A, C, B1, B6,
B12, C, D, and K; folate; thiamine; iron; zinc; and selenium
[33]. All patients are instructed to start ProCare M.D.
(NutrEssential Inc.) 3 weeks prior to their surgery and con-
tinue until healed at about 4–6 weeks after surgery. Since
2006, we have been using ProCare M.D. that is specifically
formulated to meet the needs of MWL patients for body con-
touring surgery. ProCare M.D. is a comprehensive formula
of protein, free amino acids, arginine, glutamine, and dietary
nucleotides, as well as vitamins A, C, B6, and B12, folate,
thiamine, iron, zinc, and selenium. Arginine and glutamine
have been deemed essential in many studies to the healing of
extensive wounds and optimization of the immune system.
Since using ProCare M.D., we and our patients have noted
accelerated wound healing and significantly lower major and
minor complication rates in many body contouring patients
[34]. For patients who do not tolerate the taste of ProCare,
we offer a similar product, ProMend from Bariatrics
Advantage.
Patients may present overweight and even obese for
body contouring surgery. We have accepted this challenge
and through our physician assistants have imitated a variety
of weight loss programs [35]. We rely on the meticulous
422
implementation of Simeon’s diet of daily human chorionic
gonadotropin hormone injections and a 500 cal diet to lose
from 15 to 40 lb of core body fat over several months prior
to surgery [35].
4 Preferred Techniques in Total Body
Lift Surgery
Beginning with the lower body lift as the initial operation
towards a TBL, we present the separate operations and their
inter-relationships. Salient features of the preoperative mark-
ings and operative steps are given with references to the
complete technical descriptions.
4.1 Lower Body Lift
The lower body lift (LBL) involves an excision and then lift-
ing of the inferior portion of the posterior and lateral torso to
sculpture and raise the hips, lateral thighs, and buttocks.
Usually, LBL is part of abdominoplasty, lateral thigh lift, and
buttock lift. There is limited contour improvement of the
waist from liposuction. We find that the ultimate waist shape
depends far more on the subsequent upper body lift.
Routinely LBL is combined with abdominoplasty, with the
added benefit of lifting the anterior thighs. LBL can be an
isolated procedure such as when an abdominoplasty was pre-
viously performed, although a revision of abdominoplasty is
usually needed. The circumferential abdominoplasty or as
sometimes referred to as a belt lipectomy limits correction to
the lower abdominal laxity, hip and lower back, and waist
contours. Our rare use of the belt lipectomy (circumferential
abdominoplasty) is reserved for the overweight patient,
where minimal contour finesse and lift can be achieved.
The LBL markings start with a superior incision line
roughly across the iliac crests that slightly descends to the
posterior midline. The inferior incision then demarcates the
extent of excision that will not only remove the excess skin
over the upper buttocks and lateral thighs but also lift these
areas. By gathering the excess skin with the leg abducted, the
widest resection is over the greater trochanter. With the
patient lying prone, the tissue excision is performed at com-
parable depths with a surgeon working on each side.
Subsequent to the tissue excision, the buttock tissues are
sutured to the lower back incision, which elevates and
secures the buttocks at an appropriately marked position on
the lower back. As the buttock lift results in flattening of the
buttock region, we often combine this procedure with but-
tock augmentation using an adipose fascial flap of lower
back tissue. The upper lateral thighs are undermined using a
Lockwood dissector and elevated and secured onto the tensor
fasciae latae and the upper incision line. Quilting sutures of
D.J. Hurwitz and S. Agha-Mohammadi
the advanced lateral thighs onto the deep fascia closes the
dead space to retard seroma and reduces the lateral thigh cir-
cumference. Superior to this closure, excess waist fat may be
removed directly or through liposuction. This results in a
smoother contour of the outer thigh skin and recreates the
waist concavity.
4.2 Buttock Augmentation
Buttock attractiveness varies by culture. Genetics, weight
gain and loss, aging, and pregnancies dramatically influence
buttock shape. Ideal buttock contours are round or “A”
shaped with a smooth inward sweep of the lumbosacral area
below a concave waistline. There should be minimal or no
sagging of the buttock tissue over the inferior gluteal crease
that separates the buttock from the thigh.
MWL patients have lower torso rolls that overwhelm the
buttocks, as they deflate, broaden, and sag over the upper
posterior thigh region. Buttocks also lose projection and
roundness. In combination with the hip roll, the buttocks
widen and lengthen. Advanced correction shortens, lifts, and
fills out the buttocks with use of excess lower back tissue
and/or lipoaugmentation. Typically, MWL patients request
smaller buttocks, because they regard the hip roll as part of
the buttocks. Women want narrower hips, which if taken too
far androgenizes their shape. They need to be educated that
aesthetic buttock contouring procedure has 5 aims: (1) to lift,
(2) to recreate a V-shaped superior border, (3) to decrease the
width, (4) to enhance the projection and contour, and (5) to
transform to an overall “A” or round shape.
As LBL flattens the buttocks, virtually all MWL patients
benefit from buttock augmentation. If they accept the
enlargement and the added costs and risks of flap surgery,
supramuscular gluteal pockets are created to accommodate
deepithelialized excess upper buttocks and lower back tissue
as paraspinous flaps. The buttocks are then lifted to the lower
back to construct the V-shaped demarcation of the buttock
region and lower back. The buttock width is reduced through
lateral closure of LBL.
In those patients who do have inadequate local tissue, but-
tock lipoaugmentation is employed. Some plastic surgeons
prefer silicone implants, but we do not feel they are suitable
during an LBL. We prefer lumbar flap buttock adipose fas-
cial flap augmentation first and then lipoaugmentation, espe-
cially to the lower buttock pole to lift, fill, and round the
contours. Fat is obtained from any area that is marked for
excision. Following low-pressure lipoaspiration, the fat is
washed with antibiotic solution, passed through a strainer,
packed into 20 cc. syringes, and slowly injected into the but-
tock fat as 2 mm wide long strands. Thus, the buttocks can be
contoured to the desired shape and size. The fullness and
projection of the buttocks can be greatly increased by
Plastic Surgery in Massive Weight Loss Patients
layering many fine layers of fat micrografts throughout the
buttock region.
4.3 Thighplasty
Thighplasty began with correction of the saddlebags by
LBL. The thigh needs to be reshaped and lifted circumferen-
tially. In the MWL patient, upper inner transverse thighplasty
as described by Lockwood is rarely adequate [36], so we gen-
erally perform one of three different types of thighplasty: the
spiral thigh lift, the vertical thighplasty, or the T-thighplasty.
Our spiral thigh lift addresses upper anterior, medial, and
posterior thigh laxity. The spiral lift can be considered a
Lockwood anchor medial thighplasty with a posterior exten-
sion or a limited Pitanguy thighplasty with an anterior exten-
sion [36, 37]. In either case, we include suture approximation
of the posterior thigh subcutaneous fascia to the ischial
tuberosity. Together with a lower body lift, the procedure
provides circumferential thighplasty to the upper thigh. It is
marked supine with the thigh abducted to find the labia/thigh
junction and adducted to estimate the width of resection
[28]. As LBL is being completed in the prone position, spiral
medial thighplasty starts with a crescent incision along the
lower buttocks near the inferior gluteal fold. As premarked,
parallel incisions are made on the upper posterior thigh to
remove the excess skin and fat between these incisions. The
posterior thigh skin is undermined deep to the fasciae latae
and then is elevated to a higher position and suture secured to
the unexposed periosteum of the ischial tuberosity with large
interrupted braided sutures. The inferior gluteal fold is then
meticulously sutured with Quill SRS. The patient is then
turned supine for correction of the remaining laxity of the
medial thigh. The roughly parallel inferior gluteal and upper
posterior thigh incisions are continued along the labia majora
to within the groin crease at the junction of the thigh and
pubic area and across the upper inner thigh to remove a band
of excess tissue from the medial thigh. The inner thigh is
lifted and secured at a higher position to the underlying pubic
periosteum and Colles’ fascia as in the Lockwood anchor
medial thighplasty [36]. The groin crease is then recon-
structed where the scars are often undetectable under cloth-
ing. The spiral thigh lift combines the incisions of the thigh
lift with that of an LBL to demarcate the buttocks and
improve the thigh contour circumferentially.
A vertical thighplasty circumferentially treats loose skin
of the mid- and lower thighs. A thigh-long ellipse of skin of
the medial thigh is removed through a vertical excision that
starts at the groin crease and extends to the inner knee. As
an isolated procedure it offers circumferential reduction
without a lift. Thus, it has limited use by itself only. For
MWL patients who have lost significant weight and present
with significant thigh laxity, we combine the vertical thigh-
423
plasty and the spiral thigh lift to obtain thigh circumferential
reduction and lift. Whereas most underpants cover the scars
after the spiral thigh lift, the vertical thighplasty scar can be
seen along the inner thighs. When the scar is placed poste-
rior to the mid-medial axis, it is not readily seen (Figs. 5, 6,
and 8).
5 Abdominoplasty
Abdominoplasty begins when the patient is turned supine
after LBL and perhaps also the completion of the posterior
portion of the spiral thighplasty. If the Fleur-de-Lis pattern is
not chosen, then all the skin between the umbilicus and pubis
is excised. Seromas can be avoided if one leaves behind a
generous layer of sub-Scarpa’s adipose tissue, especially over
the groin areas. Only the midline muscular fascia needs to be
stripped clean for vertical imbrication of the diastasis recti.
Hurwitz has found a horizontal running #2 PDO Quill SRS
rapid and effective approximation of midline abdominal wall
laxity. Liberal UAL (lipoplasty) of the epigastrium can be
performed, if care is taken to not surgically undermine and
cut the paramedian rectus abdominis perforators. Midline
epigastric skin tension is created by our modified version of
umbilicoplasty of the high central tension abdominoplasty
[38]. The 2–4 cm wide umbilicoplasty opening is placed in
the temporarily positioned superior abdominal flap about
2 cm superior to the deeply situated the cutout umbilicus.
Without removal of tissue, three small deepithelialized flaps
are created. Using pull-through 2–0 monofilament absorbable
sutures, the tips of these flaps are pulled inferiorly to be
sutured to the 3, 6, and 9 O’clock positions in the rectus fascia
around the retained island umbilicus. Thus, all the central ten-
sion is transmitted through the dermal flaps of the abdominal
wall flap to the rectus fascia with some relaxation of the high
tension between the umbilicus and pubis. There is no tension
along the skin closure of the island umbilicus cutout to the
abdominal flap. If an upper body lift is planned, then residual
paramedian epigastric and mid-torso skin rolls along with a
descended breasts will be corrected by reverse abdomino-
plasty, superior repositioning of the inframammary folds, and
breast reshaping.
When there is a belt-like transverse adherence of skin
around the level of the umbilicus, this thinned tissue should
be included in the resection, or it will form a new transverse
depression and adherence below the umbilicus (Fig. 3). The
flanks may still be full and will need liposuction. When the
mons pubic ptosis is severe, we prefer the three-sided pic-
ture frame monsplasty [2] (Figs. 1, 5, 6, and 8). The superior
side of the mons is pulled tight by abdominoplasty. The lat-
eral skin-only excisions along the superior extension of the
spiral thighplasty will properly shape the mons (Figs. 5, 6,
and 8).
424 D.J. Hurwitz and S. Agha-Mohammadi

Fig. 5 (a–d) These are the thighs

a b
of a 34-year-old MWL patient,
with BMI of 31, who was
self-referred after an upper body
lift and abdominoplasty done
elsewhere. Multiple views of the
surgical markings of the thighs
for a combination of spiral
thighplasty and a long vertical
medial thigh excision extension
show the planning with
ultrasonic-assisted lipoplasty
(UAL) of the excision site as well
as the anterior thighs, superior
buttocks, and left lateral thigh. In
addition there is a three-sided
picture frame pubic monsplasty
to correct the dome shape of the
region after a suture suspension
during her prior abdominoplasty.
The spiral excision is drawn
between the buttocks and upper
thigh and spirals around the
medial thighs to end along side
of the labia majora to meet the
abdominoplasty scar. The upper c d
portion of the vertical excision is
seen anteriorly and the lower
portion is seen posteriorly to end
medial to the popliteal fossa.
Despite her girth, her thigh
tissues were very lax, indicating
combined liposuction and
excision

5.1 Upper Body Lift (UBL)
Upper body lift is an excision of mid-torso back rolls that
usually includes a reverse abdominoplasty and either
reshaping of the breasts or correction of gynecomastia. As
the short limb of L brachioplasty extends along the lateral
chest to the inframammary fold, a brachioplasty is often
added to UBL [23]. UBL often follows 3 months after LBL,
but may be combined in a single operative session. There are
two types of UBL: Type 1 is a bra line excision of moderate
to severe mid-torso rolls. Type 2 is a vertical J-shaped exci-
sion that extends from the IMF up the lateral chest to the
axilla. Type 2 is used for mild to moderate mid-torso laxity
or when the patient refuses a back scar.
Type 1 UBL markings are posterior extensions of the lat-
eral and IMF Wise pattern mastopexy incisions (Figs. 1 and
3). The proper width of resection is achieved when all verti-
cal redundancy is removed by gathering the skin. When UBL
is combined with LBL, care is taken to adequately separate
these excisions with caution taken to avoid over-resection of
tissues. Whereas the LBL excision crosses the lower mid-
line, that is the case in only the most severe mid-torso skin
Plastic Surgery in Massive Weight Loss Patients 425

Fig. 6 (a–d) The same views of

the thighs 7 months after her 3-h
a b
combined 3,000 cc. UAL and
spiral thighplasty with a vertical
extension. Appropriate thigh
contours and skin turgor as well
as mons pubis shaping are
established with inconspicuous
scars

c d

sagging. Scars crossing the mid-posterior midline disrupt the
aesthetically beautiful feminine back contours and as such
should be avoided. Since the skin is always adherent to the
posterior spinous region, it is only the chasing of dog ears
that forces the midline crossover of the excision. Even when
shortened, the mid-torso back scars may stay thickened for
prolonged periods and ultimately may widen more than any
other scar. However, often they heal as well as the other
scars.
Both type I and 2 UBLs are usually performed with a
reverse abdominoplasty to correct anterior upper abdominal/
lower thoracic laxity. Once the abdominoplasty excision in
the lower abdomen is accounted for, then the excess upper
abdominal skin can be marked out from the IMFs. If the tis-
sue can be used to augment the inferior pole of the breasts,
then it is planned as an inferior deepithelialized continuation
of the Wise pattern mastopexy. In women, the reverse
abdominoplasty is suspended to the new IMF on the sixth
rib. In men, the reverse abdominoplasty is suspended to the
boomerang pattern correction of gynecomastia. Most MWL
patients need a reverse abdominoplasty to fully correct their
anterior torso laxity [39].
Type 1 (bra line excision) is performed prone with har-
vesting of the transverse tissue over the latissimus dorsi
426
Fig. 7 The before breast photos (upper) of a 25-year-old MWL patient
with a BMI of 22.5 show markings for concentric ring mastopexies,
dashed lines of the pectoralis muscles, and midline and meridian lines
of the breast. After mastopexy, 325 cc gel implant augmentation and
Fig. 8 Key intraoperative photos of the patient seen in Fig. 5. The
upper photo shows the cut to size Strattice implant over the deepitheli-
alized NAC. The lower photo shows retraction of thin breast flaps to
expose the Strattice sewn to the pectoralis muscle over the gel implant
D.J. Hurwitz and S. Agha-Mohammadi
acellular dermis (Strattice, LifeCell, New Jersey) sling support 8
months later. The implants remain in good position with no expansion
of the lower poles as seen in Fig. 1
fascia and either discarded or retained as a laterally based
deepithelialized intercostal perforator flap for breast reshap-
ing. As part of a single-stage total body lift, UBL is not
started until the operator is confident of his/her ability to
close the LBL excision sites. The patient is turned prone and
abdominoplasty is continued first, making sure the UBL
markings are accurate. If abdominoplasty was previously
performed, then there is usually considerable epigastric
excess to remove through UBL.
The type 2 or J-shaped UBL is a crescent-shaped resec-
tion of lateral chest skin and fat followed by discontinuous
undermining over the latissimus dorsi muscle and suture
advancement of the SFS of the lateral chest flap to the ser-
ratus muscle and fascia. Care is taken to avoid injury to the
long thoracic nerve. There will be some scalloping of the
longer advanced side that tends to smooth out over time. A
secured advanced flap will aesthetically demarcate the lateral
border of the breast. Otherwise an unsecured advancement
back flap may recede to lateralize the breast.
Plastic Surgery in Massive Weight Loss Patients 427

b
Fig. 9 (a–c) These photos show
the application of
radiofrequency-assisted
lipoplasty (RFAL) to remove
retained fat and contract the skin
in the lateral thighs and above the
knees after lower body
contouring in a 57-year-old, with
BMI of 27, MWL patient with
poor skin quality. (a) shows the
markings for abdominoplasty, a
picture frame mons pubisplasty,
an LBL, spiral thighplasty with
vertical extension, and UAL of
her oversized suprapatellar
regions. (b) Thirteen months later
she is marked along each
trochanter and on the knees for
RFAL of 68 Kwatt/J for removal
of 500 cc from the right knee,
400 cc from the left knee, 300 cc
from the right lateral thigh, and
200 cc from the left thigh. (c)
The result 4 months later shows
correction of the residual contour
deformity with RFAL and no
skin excisions

5.2 Breast Reshaping
The breast deformity after MWL is evaluated in isolation and as
part of overall torso skin laxity. Virtually all MWL patients will
require a breast lift (mastopexy). Usually, we use a Wise pattern
in order to remove excess, poorly elastic skin. Breast volume
becomes the determinant of the procedure. If there is adequate
breast volume, a dermal suspension mastopexy is performed
(Fig. 3) [40]. Unlike the standard Wise pattern breast reduction
technique that relies on the skin to conform the breast shape, the
dermal bra suspension aims to restore breast shape through a
combination of internal suturing of breast parenchyma and
428
Fig. 9 (continued)
c
dermal plication. It also suspends the superior dermal pedicle of
the breast to the second rib periosteum. If macromastia is pres-
ent after MWL, a breast reduction is done, which may include a
dermal suspension. If there is inadequate breast volume, a breast
augmentation with either silicone implants or nearby flaps is
performed. Spiral flap reshaping incorporates UBL into breast
reshaping (Fig. 1) [2, 41].
When silicone implants or autogenous flaps are used, a
secure IMF is important. When the base or footprint of the
breast has lowered, it should be raised. It is secured by
creation of a new IMF with permanent braided suture
attachment of the subcutaneous fascia (SFS) of the
advanced reverse abdominoplasty flap along the sixth rib
[2]. A secure IMF may be all that is necessary to prevent
bottoming out of the inferior poll of the breast; however,
Hurwitz prefers to use in the most atrophied breasts a
large sheet of acellular dermis as a permanent hammock
support of silicone gel implants by bridging the inferior
border of the pectoralis muscle with the new IMF (Figs. 7
and 8) [42].
Our patients prefer autogenous flaps to silicone implants.
The spiral flap uses upper abdominal and lateral thoracic
excess tissue not only to add volume but also to suspend. The
deepithelialized lateral thoracic flap is placed in a tunnel to
establish long-lasting superior pole fullness and a smooth
transition from the lateral breast to the axilla. The deficient
inferior pole of the breast is filled and supported by a flip-up
flap of epigastrium (Fig. 1).
D.J. Hurwitz and S. Agha-Mohammadi
The markings of the Wise pattern mastopexy, spiral
flaps, and UBL are intertwined [2, 43]. The deepithelial-
ized, harvested lateral thoracic flap is attached to the ser-
ratus fascia and lateral border of the central breast mound.
The deepithelialized epigastric flap is attached to the cen-
tral mound. When the surgeon is confident of the residual
laxity after the standard abdominoplasty, then the epigas-
tric extension can be harvested for the breast. By suturing
the rotated and advanced lateral thoracic flap to the second
rib cartilage and the epigastric flap to the fifth cartilage,
the spiral flap shapes and suspends the breast mound. Then
the Wise pattern flaps are draped over the shaped breast
mound. By this time the arm limb of L brachioplasty is
closed, and the final decision can be made on the width and
length of the vertical (chest) limb excision of the L
brachioplasty.
5.3 Brachioplasty
L brachioplasty involves excisions of a longitudinal hemi-
ellipse of the medial arm and crescentic lateral chest skin
excisions connected by an inverted V excision across the
axilla [23, 44]. This brachioplasty is designed for correction
of severe arm laxity, axillary ptosis, and upper chest laxity
(Figs. 1 and 3). Preliminary excision site liposuction (ESL)
allows for skin excision only, leaving behind important sub-
cutaneous neurovasculature. Then an anchoring deep suture
Plastic Surgery in Massive Weight Loss Patients
suspends the proximal posterior flap to the deltopectoral
fascia. The width of the vertical chest limb can only be deter-
mined after breast reshaping has been completed. L
brachioplasty completes the total body lift.
6 Complications
We published a 5-year retrospective clinical review of our
initial 75 consecutive completely treated massive weight loss
patients [3]. Age averaged 43.4 years (21–68 years). The
mean BMI of the 75 patients was 29.3 (21.6–39). The mean
BMI of the 16 multistaged patients was 30.3. There were 59
single-stage, 15 two-stage, and 1 three-stage TBL, having
605 separate procedures, for an average of 8.0 per patient.
Single-stage total body lift surgery averaged 8.2 h. Two-
stage surgery took 7.4 h for the first stage and 4.6 h for the
remaining stage, for a total of 12 h. Banked blood transfu-
sions for single stage were 1.5 per single-stage case and .78
per multistaged. Seventy-six percent of the patients experi-
enced complications, mostly related to wound healing.
Delayed wound healing and seromas were the most common
complications. Incision lines that dehisced and/or suffered
necrosis and failed to heal within a month of surgery were
considered complications.
Fifteen of the 50 single-stage patients (25 %) suffered
major complications (2-month delay or an unscheduled
return to the hospital). Six of the 16 (40 %) multistaged TBL
patients had major complications. These major complica-
tions included multiple, infected, and recurrent seromas, but-
tock adipose flap necrosis, prolonged edema, chest hematoma
that required drainage, thigh abscesses, spiral flap tip necro-
sis, pulmonary embolism, and Clostridium difficile pseudo-
membranous colitis resulting in total colectomy.
Residual and recurrent skin laxities as well as unwanted
retained adipose are common problems of body contouring
in the MWL patient that are accentuated by further shifts in
body weight. While major but localized excisions with lipo-
suction have been our usual approach to correct these prob-
lems, recently we have successfully applied the contraction
potential of radiofrequency-assisted lipoplasty through
BodyTite, Invasix (Tel Aviv, Israel), in 17 overweight or
MWL patients (Fig. 7) [45].
7 Informed Consents
Obtaining an informed consent for multiple interrelated
operations is a complex process that has been aided by my
patient education book, Total Body Lift. An informed consent
document for the first stage of total body lift surgery, abdom-
inoplasty, lower body lift, and medial thighplasty follows. In
its usual format the patient initials each page.
429
Pearls and Pitfalls
• Total body lift surgery is an approach, not a tech-
nique, to treating the contouring needs of the mas-
sive weight loss patient.
• TBL surgery is the comprehensive aesthetic correc-
tion of deformity after weight loss and/or aging, in
a few stages as safely as possible.
• The safety and efficacy of single-stage TBL by our
experienced and organized team are established.
• There are adamant critics to TBL that pose a medi-
colegal challenge.
• In the absence of the TBL approach, many patients
fail to achieve complete correction of their MWL
deformities.
• There are over 50 % minor wound healing compli-
cations with multiple major operations.
• Optimal nutritional and medical preparation is
important, aided by providing a comprehensive pro-
tein supplement.
• Some patients experience unacceptable skin laxity
months after the body contouring surgery, leading
to secondary surgery.
Informed Consent for Abdominoplasty/Lower Body
Lift/Thighplasty
Instructions
This is an informed consent document that has been prepared
to help Dr. Dennis J. Hurwitz and his staff inform you on
the combination operations of abdominoplasty, lower
body lift, and medial thighplasty and their risks, as well as
alternative treatments.
It is important that you read this information carefully and
completely. Time will be set aside for you to ask ques-
tions to Dr. Hurwitz or his staff. Please initial each page,
indicating that you have read and understand the page
and sign the consent for surgery as proposed by
Dr. Hurwitz.
Introduction
With aging, following pregnancies, or massive weight loss,
there are a set of body contouring procedures that remove
unwanted loose skin and fat from the lower torso and
thighs and then reshape them. After that region is
addressed, the surgical rehabilitation is commonly com-
pleted on the mid-torso, breasts, and arms. That second
session is an upper body lift, which consists of a reverse
abdominoplasty, removal of mid-back rolls, establishing a
higher fold under the breast, and reshaping of the breasts.
Although that scenario is our most common approach,
some procedures may not be done.
430
This consent form deals with surgery of the lower body and
thighs, which is often the first part of what Dr. Hurwitz
calls a total body lift. Since joining the UPMC (University
of Pittsburgh Medical Center) Minimally Invasive
Bariatric team in 1999, Dr. Hurwitz has gained consider-
able experience in body contouring surgery and is an
innovator and an internationally recognized teacher in
this field. No longer a full-time member of the UPMC
team, he is currently the director of the Hurwitz Center
for Plastic Surgery with offices in Pittsburgh and
Philadelphia (Chadds Ford), Pennsylvania, and in
Southern California (www.hurwitzcenter.com). He com-
prehensively evaluates your facial, extremity, and torso
contouring needs. Dr. Hurwitz will offer the procedures
and staging that address your body contour concerns,
your resources, and your level of acceptance of risk. Many
patients begin with the lower body and have the upper
body worked on at a second stage at least 3 months later.
A single-stage total body lift is considered in suitable can-
didates. We strongly recommend reading his book, Total
Body Lift, available from the office at no charge, for in-
depth discussions of this surgery and presentation of
patient experiences.
The lower body lift is an operation that removes a horizontal
strip of excess skin and fatty tissue from the hips, outer
thighs, lower back, and buttocks. The lower body lift is
combined with an abdominoplasty, which removes excess
skin between the umbilicus and pubic region. After under-
mining and at times liposuction, the buttocks and outside
thighs are pulled up and tightly sutured to the lower torso
skin. Then the upper abdominal skin is pulled down and
sutured to the groin and pubic region after tightening the
central muscles of the abdominal wall. Together these
operations raise the buttocks, hips, and thighs and tighten
the abdomen. The removal of excess skin between the
navel (umbilicus) and pubis is called a panniculectomy,
which is designed to correct the problem of chronic skin
rashes and infection due to overlapping folds of lower
abdominal skin. Independently or as part of a complete
abdominoplasty, panniculectomy, as a medically indi-
cated operation, may be covered by insurance. As opposed
to lower body lift with abdominoplasty, a circumferential
abdominoplasty is a belt-like removal of excess skin and
fatty tissue from the middle and lower abdomen, continu-
ing around the hips to the center of the lower back, result-
ing in tightening of the lower torso but no lift to the thighs,
hips, or buttocks. A medial thighplasty completes the
series of operations with removal of loose skin of the
inner thighs. You will have either an upper medial
thighplasty with removal of a crescent shape of thigh skin
below the labia majora or a vertical medial thighplasty
with removal of a long strip of skin from the groin to the
knee. Whereas the scars after abdominoplasty, lower body
D.J. Hurwitz and S. Agha-Mohammadi
lift, and upper medial thighplasty are covered by under-
wear, the vertical medial thighplasty scar will be seen
when the inner thighs are exposed.
Body contouring surgery is not a treatment for obesity. Obese
individuals who intend to lose weight should postpone body
contouring surgery until they have been able to adequately
reduce and maintain their weight loss. The tight closure of
excessively fatty tissues is more likely to be followed by
wound healing complications. Furthermore, significant
weight loss after body contouring surgery could result in
undesirable contours and sagging of skin. Liposuction may
play a role in removing large amounts of excess fat.
This multiple operation will be scheduled at UPMC Magee
Women’s Hospital, because that is a nearby well-equipped
facility with my experienced team of anesthesiologists,
plastic surgery residents, nurses, and technicians. We
encourage you to complete EMMI, the Internet hospital-
based informed consent that supplements this information.
Alternative treatments
Alternative forms of management consist of not treating the
areas of loose skin and fatty deposits. Suction-assisted
lipectomy surgery may be a surgical alternative to abdom-
inoplasty and thighplasty if there is good skin tone and
localized abdominal fatty deposits in an individual of nor-
mal weight or a mildly overweight individual. Diet and
exercise programs may be of benefit in the overall reduc-
tion of excess body fat, but will not tighten skin. Risks
and potential complications are associated with alterna-
tive surgical forms of treatment.
Risks of Abdominoplasty/Lower Body Lift/Medial
Thighplasty
Every surgical procedure involves a certain amount of risk,
and it is important that you understand these risks and the
possible complications associated with them. In addition
every procedure has limitations. An individual’s choice to
undergo any surgical procedure is based on the compari-
son of the risk to potential benefit. You should discuss
each of them with Dr. Hurwitz or his staff to make sure
you understand all possible consequences of this combi-
nation of procedures.
Specific Risks of Lower Body Lift Surgery
Recurrent Skin Laxity: Unpredictable and undesirable laxity
of the skin with sagging and/or depressions may occur
some weeks to months after this surgery. Revision surgery
at additional costs would be recommended.
Pubic Distortion: It is possible, though unusual, for women
to develop distortion of their labia and pubic area. Upper
inner thigh scars may descend or widen leading to
exposure down the thighs. Should this occur, additional
surgery may be necessary.
Plastic Surgery in Massive Weight Loss Patients
Delayed Healing: Due to the high tension closure through
subcutaneous tissue, wound disruption or delayed wound
healing is possible. Some areas of skin may die. That
would require debridement (removal of dead tissue) in the
office, frequent dressing changes, or further surgery to
remove the non-healed tissue. The wounds may be
encouraged to heal in over weeks or be closed with sutures
secondarily. Smokers have a greater risk of skin loss and
wound healing complications.
Umbilicus: Malposition, scarring, unacceptable appearance,
or loss of the umbilicus (navel) may occur.
General Risks of Surgery
Healing Issues: Certain medical conditions, dietary supple-
ments, and medications may delay and interfere with heal-
ing. Patients with massive weight loss may have a healing
problem that could result in the incisions coming apart,
infection, and tissue loss resulting in the need for addi-
tional medical care, surgery, and prolonged hospitaliza-
tions. To reduce these risks, you must follow directions on
our dietary supplements. Patients with diabetes or those
taking medications such as steroids on an extended basis
may have prolonged healing issues. Smoking will cause a
delay in the healing process. Patients with significant skin
laxity (patients seeking facelifts, breast lifts, abdomino-
plasty, and body lifts) will continue to have the same lax
skin after surgery. The quality or elasticity of skin will not
change and some recurrence of skin looseness will occur.
There are nerve endings that may become involved with
healing scars during surgery such as suction-assisted
lipectomy, abdominoplasty, facelifts, body lifts, and
extremity surgery. While major nerve injury is unlikely,
small nerve endings during the healing period may become
too active producing a painful or oversensitive area due to
entrapment in scar tissue. Often massage and early nonsur-
gical intervention resolves this. It is important to discuss
postsurgical pain with Dr. Hurwitz.
Postoperative swelling is due to direct injury to tissues and
generalized hormonal-based retention of fluid. While
always unwelcome, at times swelling can be massive. We
offer a variety of new modalities to reduce swelling,
improve healing, and reduce scarring. The HIVAMAT
improves lymphatic flow and reduces localized pain
through electrostatic vibratory therapy. A personal treat-
ment machine is available for home use twice a day for
nominal rental. For prolonged firmness and pain in the
tissues, we offer the MedX Phototherapy System to
deliver highly effective and efficient protocol of superlu-
minous diode and low-level laser therapy. Lymphatic and
deep massage therapies are also provided in our nearby
Hurwitz Center for Rejuvenation medi spa.
Bleeding: Due to the extensive nature of these operations, it
is possible that you will lose enough blood to warrant
431
transfusions from volunteer-donated blood from the hos-
pital blood bank. If at all possible, one to two units of
blood could be donated by you in advance. Our anesthesi-
ologist offers normovolemic hemodilution, whereby sev-
eral units of blood are removed from you after starting
your operation with immediate replacement with intrave-
nous fluids. Your saved blood will be returned to you at
the end of the operation. Should postoperative bleeding
occur, it may require emergency treatment to drain accu-
mulated blood and further blood transfusion. If you wish
to minimize transfusion risk, then multiple operative ses-
sions are an alternative. Do not take any aspirin or anti-
inflammatory medications for ten days before surgery, as
this will increase the risk of bleeding. Nonprescription
“herbs” and dietary supplements can also increase the risk
of surgical bleeding. We will provide the supplements
that you need for optimum healing.
Infection: Major infection with fever and large areas of red
skin (cellulitis) is unusual after this type of surgery.
Should a serious infection occur, treatment including
intravenous antibiotics or additional surgery to remove
dead tissue and drain abscesses may be necessary. Minor
wound infections accompanied by exposed and “spitting”
sutures are common and are usually easily dealt with by
limited debridement and dressing care. There is a greater
risk of infection when multiple body contouring proce-
dures are combined instead of single operations.
Dehiscence: In most areas your skin closure is in two lay-
ers. Separation of the superficial, deep, and/or both lay-
ers may occur any time during your first postoperative
month. Suture breakage, knots untying, sutures tearing
through, too much movement or bending, and skin
necrosis cause dehiscence. Broken superficial skin
sutures may be urgently replaced. Deep dehiscence may
require return to the operating room for closure under
anesthesia. These healing problems would require fre-
quent dressing changes, considerable cost of supplies,
extra office visits, and sometimes further debridement.
Open wounds may take weeks to heal or secondary clo-
sure may be appropriate. Wounds allowed to heal on
their own usually benefit from later scar revision.
Smokers have a high risk of skin loss, infection, and
wound healing complications. Do not smoke a month
before or after your body lift surgery.
Seroma: Drains are often placed at the end of the operation
to collect leakage of injected and body fluids. The smooth
silicone drains are removed with usually minimal pain in
about ten days when the drainage is less than 50 cc each
day. Nevertheless, sometimes serum accumulations occur
underneath the skin. Should this problem occur, the serum
would be aspirated by needle and syringe in the office on
one to several occasions. If the seroma fluid returns, a new
drain is placed in the seroma cavity.
432
Change in Skin Sensation: Postoperative diminished (or loss
of) skin sensation (numbness, pins and needles sensation,
burning, or itching) and/or pain in the lower torso and
thighs may be temporary or very rarely permanent.
Skin Contour Irregularities: Contour irregularities and
depressions may occur after these procedures. Visible and
palpable looseness and wrinkling of skin can also occur.
Asymmetrical fullness, bulges, and depression may be
present.
Skin Scarring: These scars are very long. Despite the best
effort by Dr. Hurwitz, scar appearance and healing ten-
sions are not fully predictable. The scars may be uneven,
excessively wide, and asymmetrical and/or out of opti-
mum position. While widened, hypertrophic and keloid
scarring are uncommon and sometimes unsightly scars
may result. Scars may be asymmetric and hyperpig-
mented. Additional treatments including surgery may be
necessary to treat excessive scarring.
Allergic Reactions to Medications: Serious adverse reactions
may occur to drugs used during surgery and later pre-
scription medicines. Immediately report a rash, diarrhea,
or breathing difficulties as those may be signs of serious
complications. Allergic reactions may require additional
treatment.
Pulmonary Complications: Pulmonary complications may
occur secondarily to blood clots (pulmonary emboli),
pneumonia, or partial collapse of the lungs after general
anesthesia. Should either of these complications occur,
you may require hospitalization and additional treatment.
Pulmonary emboli can be fatal.
Long-Term Effects: Subsequent alterations in body contour
may occur as the result of aging, weight loss or gain,
pregnancy, or other circumstances unrelated to the above
procedures. Since sutures are used to tighten abdominal
muscle fascia, their ability to hold the abdomen flat is
unpredictable. Therefore, unwanted postoperative abdom-
inal fullness may occur.
Pain: Chronic pain occurs infrequently from nerves becom-
ing trapped in scar tissue.
Poor Aesthetics: You may be disappointed with your postop-
erative appearance. Undertreatment with residual laxity
and looseness or overtreatment with excessive tightness of
skin can occur with flattening of regional contours and wid-
ening or thickening of scars. Some loose tissue always
remains because torso skin laxity also occurs in the vertical
direction, which is not fully treated. Considerable judg-
ment is used to achieve the optimum shape and skin turgor,
but for a variety of reasons the final appearance may be
suboptimal and that risk must also be understood. At times,
it is desirable to perform additional procedures to improve
your appearance which may increase your costs.
Complications of Anesthesia: Both local and general anesthe-
sia involve risk, which will be discussed by your anesthe-
siologist on the day of surgery. If you have chronic or
D.J. Hurwitz and S. Agha-Mohammadi
difficult to control medical problems, a presurgical consul-
tation with a Magee Women’s Hospital anesthesia repre-
sentative should be scheduled. Regardless of your health,
there is the remote possibility of complications, injury, and
even death from sedation or general anesthesia.
Additional Surgery
Recognition of Dr. Hurwitz by surgeon peers or the public
media does not infer that complications can be avoided or
that the best results will be achieved. Based on past expe-
rience, improvement in your condition with low morbid-
ity is anticipated. Nevertheless, there is no guarantee or
warranty expressed or implied on the results that may be
obtained. Even though risks and complications occur
infrequently, the complications associated with abdomi-
noplasty, upper body lift, and medial thighplasty are addi-
tive. The more operations performed at a single session,
the more likely that revision surgery will be needed. The
practice of medicine and surgery is not an exact science,
so I am still learning how to apply the optimal combina-
tion of procedures to each patient. Should complications
occur, or aesthetic expectations be unmet, additional pro-
cedures or other treatments are likely to be recommended.
Dr. Hurwitz is prepared to provide mutually agreed upon
follow-up corrective surgery at a reasonable cost. Our
doctor-patient relationship continues well beyond your
initial complex operation. Agreeing with this treatment
plan and accepting the risks as presented in this document
imply a willingness to comply with follow-up care by Dr.
Hurwitz. Should you choose to continue care with another
plastic surgeon, Dr. Hurwitz will facilitate the transfer of
information to that doctor, but Dr. Hurwitz accepts no
responsibility for the planning, arrangements, or costs of
subsequent care by another plastic surgeon.
Health Insurance
Most health insurance companies exclude coverage for cos-
metic operations such as abdominoplasty, lower body lift,
and inner medial thighplasty. Your insurance company may
not pay for complications that might occur from surgery.
Payment is anticipated if you suffer postoperatively from a
medical condition, such as cardiac arrhythmia, pneumonia,
urinary tract infection, etc. Please carefully review your
health insurance subscriber information pamphlet. If your
hanging panniculus is symptomatic for recurring chronic
rash or infections or chronic disabling back ache, then our
office is likely to help you obtain some financial relief.
Financial Responsibilities
The cost of surgery involves several charges for the services
provided. The total includes fees charged by Dr. Hurwitz,
the hospital, anesthesia, laboratory tests, and possible
outpatient hospital charges, depending on where the sur-
gery is performed. Depending on whether the cost of
Plastic Surgery in Massive Weight Loss Patients
surgery is covered by an insurance plan, you will be
responsible for necessary co-payments, deductibles, and
charges not covered. Additional costs may occur should
complications develop from the surgery. Secondary sur-
gery or hospital day-surgery charges involved with revi-
sionary surgery would also be your responsibility.
Disclaimer
Informed consent documents are used to communicate informa-
tion about the proposed surgical treatment of a disease or
condition along with disclosure of risks and alternative forms
of treatment(s). The informed consent process attempts to
define principles of risk disclosure that should generally
meet the needs of most patients in most circumstances.
However, informed consent documents should not be con-
sidered all inclusive in defining other methods of care and
risks encountered. Dr. Hurwitz may provide you with
additional or different information which is based on all
the facts in your particular case and the state of medical
knowledge. Informed consent documents are not intended
to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of
all of the facts involved in an individual case and are sub-
ject to change as scientific knowledge and technology
advance and as practice patterns evolve.
It is important that you read the above information care-
fully and have all of your questions answered before
signing the consent.
Consent for Surgery
1. I hereby authorize Dr. Dennis J. Hurwitz and such assis-
tants as may be selected to perform the following
procedures:
Abdominoplasty/Lower Body Lift/Inner Thighplasty
I have received, read, and given ample opportunity to
asked questions of the following information:
Informed Consent for Abdominoplasty/Lower Body Lift/
Thighplasty
2. I recognize that during the course of the operation and
medical treatment or anesthesia, unforeseen conditions
may necessitate different procedures than those above.
I therefore authorize the above physician and assistants or
designees to perform such other procedures that are in the
exercise of his or her professional judgment necessary
and desirable. The authority granted under this paragraph
shall include all conditions that require treatment and are
not known to my physician at the time the procedure is
begun.
3. I consent to the administration of such anesthetics consid-
ered necessary or advisable. I understand that all forms of
anesthesia involve risk and the possibility of complica-
tions, injury, and sometimes death.
433
4. I acknowledge that no guarantee has been given by anyone
as to the results that may be obtained.
5. I consent to the photographing or televising of the
operation(s) or procedure(s) to be performed, including
appropriate portions of my body, for medical, scientific,
or educational purposes, provided my identity is not
revealed by the pictures.
6. For purposes of advancing medical education, I consent to
the admittance of observers to the operating room.
7. I consent to the disposal of any tissue, medical devices, or
body parts which may be removed.
8. I authorize the release of my Social Security number to
appropriate agencies for legal reporting and medical
device registration, if applicable.
9. It has been explained to me in a way that I understand:
a. The above procedures to be undertaken.
b. There may be alternative procedures or methods of
treatment.
c. There are risks to the procedures proposed.
I consent to the procedures and the above listed items
(1–9). I am satisfied with the explanation.
References
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Body contouring after massive weight loss, www.plasticsurgery.
org/media
2. Hurwitz DJ (2004) Single stage total body lift after massive weight
loss. Ann Plast Surg 52(5):435–441
3. Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J (2008) A clini-
cal review of total body lift. Aesthet Surg J 28(3):294–304
4. Allison DB, Fontaine KR, Manson JR (1999) Annual deaths attrib-
utable to obesity in the United States. JAMA 282:1530
5. Hedley AA, Ogden CL, Johnson CL et al (2004) Prevalence of
overweight and obesity among US children, adolescents, and
adults, 1999–2002. JAMA 291:2847
6. National Institutes of Health (1998) Clinical guidelines on the iden-
tification, evaluation, and treatment of overweight and obesity in
adults: the evidence report. Obes Res 6(Suppl 2):51S
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weight and obesity in the United States, 1999–2004. JAMA
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8. Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK
(2008) Will all Americans become overweight or obese? estimating
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(Silver Spring) 16(10):2323–2330
9. Wang Y, Beydoun MA (2007) The obesity epidemic in the United
States–gender, age, socioeconomic, racial/ethnic, and geographic
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Epidemiol Rev 29:6–28
10. Fisher BL, Schauer P (2002) Medical and surgical options in the
treatment of severe obesity. Am J Surg 184(6B):9S
11. Sjostrom L, Lindroos AK, Peltonen M et al (2004) Lifestyle, diabe-
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 Brachioplasty
Richard J. Zienowicz and Erik A. Hoy
1 Introduction
One of the most common age- and obesity-associated
body contour problems is upper arm skin laxity. This
upper arm lipodystrophy tends to be especially pro-
nounced in female patients. The so-called “batwing”
deformity is characterized by an unsightly development of
loose hanging skin of the posterior arm and is frequently
accompanied by excess adipose tissues as well. With the
increase in frequency of bariatric procedures, body con-
touring, including brachioplasty, has been also increasing.
Though this excess tissue is characteristic of extreme
weight loss following morbid obesity in both men and
women, its presence is a complaint of a considerable
number of women of normal weight. The problem usually
becomes a fashion concern in the late forties when con-
cealment of the upper arm severely limits garment choices.
Indeed, most other body contouring problems are far more
favorably camouflaged by warm weather clothing than the
upper arm “batwing” deformities.
Even though brachioplasty (also referred to as upper
arm dermatolipectomy) typically provides reliable long-
term correction of these problem areas, the resulting scars
are some of the greatest disincentives for patients contem-
plating the procedure. These scars widen predictably, and
though hidden when the arms are positioned by the side,
they can draw attention in poses with the arms abducted.
Fortunately, we have found that a post-op program of gar-
ment ware and taping has greatly improved the aesthetic
outcome by both minimizing scar hypertrophy and expe-
diting scar maturation.
R.J. Zienowicz, MD, FACS (*) • E.A. Hoy
Department of Plastic Surgery, Alpert Medical School
of Brown University, Providence, RI, USA
e-mail: drz@bodybyz.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_30
2 Anatomy and Consequences
of the Aging Process
Glanz and Gonzalez-Ulloa described the development of the
ptotic, aged upper arm with attenuated soft tissues and sag-
ging and descent of the nadir of the posterior arm curvature
[1]. But other authors have pointed out that most patients
would prefer the contour deformity associated with upper
arm adiposity and skin excess over the long scar of a brachio-
plasty [2]. However, those patients who are especially both-
ered by the batwing deformity are willing to trade “shape for
scars.” Several authors have described different zones of the
upper arm or grouped patients in terms of the severity of
deformity to simplify diagnosis of problem areas and to aid
in preoperative planning [3–5].
3 Preoperative Planning
In addition to a systematic approach to presurgical exami-
nation of these patients, a series of photos and an exam in
front of a large mirror are vital in evaluating and instruct-
ing prospective patients in what to expect from their bra-
chioplasty procedure. Preoperative photographs should
include the standard anterior-posterior, oblique, and lat-
eral views, as well as close-up views of the arms in an
adducted position, with the force of gravity acting upon
the posterior arm tissue excess. A dynamic exam in front
of a large mirror should help educate the patient and sur-
geon about what features of aging and tissue excess are
present and which surgical approaches are indicated.
These images should be printed and readily available dur-
ing the surgical procedure for easy reference, as the anat-
omy is easily distorted in the supine position. The patient
is examined once again on the day of surgery, during the
preoperative consultation, with gentle manipulation of the
435
436
tissue of the posterior arm, and the areas of planned resec-
tion are tentatively marked. Typically, the incision place-
ment will vary slightly as the flap is tailored on the
operating table.
Initial physical exam should concentrate on determina-
tion of asymmetries. An elliptical dermatolipectomy is
always necessary and the distal apex in most cases can be
limited to the distal upper arm, not crossing the elbow.
Liposuction of the forearm just distal to the elbow is often
essential to limit scar length. To achieve a scar which
remains completely concealed with normal arm at the side
positioning requires an estimation of the laxity of the skin
on the superior edge of the extended arm. This ventral edge
comprises the thinnest skin of the upper arm. The dorsal or
inferior edge skin over the triceps muscle is typically much
thicker. Stretch marks which notoriously plague this inner
arm region should be eliminated to the greatest extent pos-
sible. We begin marking by pulling in an inferior direction
on the lax soft tissues of the extended medial upper arm
with the patient in the standing position. A lengthwise mark
is made while exerting this pull from just proximal to the
elbow to the axilla. The line is drawn into the axilla, and the
axillary skin is then pulled from the lateral edge of the pec-
toralis major in a posterior direction and brought as far
anteriorly as possible while allowing concealment within
the axilla and then a right angle line continued in the midax-
illary line.
4 Patient Selection: Indications
Evaluation begins with an assessment of the extent of upper
arm involvement. Some patients present with complaints of
upper arm fullness, but may have good skin tone and rela-
tively little excess adiposity of the posterior upper arm.
These patients, especially younger patients with preserved
elasticity of the dermis, may respond better to upper arm
suction-assisted lipectomy. This technique will not be
addressed in depth in this chapter, as it is not applicable as
a single technique for addressing more severe adiposity and
skin excess. This picture is often seen in states of obesity,
or as one of the sequelae of significant weight loss. In these
patients, both fatty tissues and skin need to be resected, i.e.,
brachioplasty or dermal lipectomy. Those with a history of
morbid obesity invariably have the most extensive upper
arm “panniculi” that are often contiguous with tissue laxity
of the axilla and lateral chest wall. This class of patients
also may have involvement of the forearm and elbow
regions requiring a longer incision for aesthetic removal of
redundant tissues. This is less frequently the case in patients
with more normal body mass indices. For further detail, the
reader is directed to a helpful algorithmic approach to these
patients [5].
R.J. Zienowicz and E.A. Hoy
5 Refining Approaches to Brachioplasty
The first aesthetic brachioplasty technique was published in
1954, by Correa-Itturaspe and Fernandez [6]. Because
patients had unacceptable cicatrical contractures, especially
in the axilla, subsequent authors sought to modify the proxi-
mal extent of the scar. Previously described Z- or W-plasties
were applied to the area to reorient the scar, and L- or T-shaped
skin paddles were resected to re-contour the arm-axillary
region [7–9]. Lockwood made a significant contribution to
the burgeoning field of body contouring with his description
of the superficial fascial system (SFS) and his method for sus-
pending the soft tissues by reestablishing this layer [10]. The
following table illustrates various researchers’ technical con-
tributions and is modified from Pinto et al. [11].
Contemporary surgeons are increasingly adept at incor-
porating the brachioplasty as part of an upper-body rejuvena-
tion in the massive weight loss patient [12–14]. In fact, the
combination of brachioplasty with upper-back resection, and
breast reconstruction, is now considered an upper-body lift
[4, 15], which is analogous to the more common lower body
lift. In a thorough analysis of their prospective registry of
body contouring patients, Gusenoff and colleagues [14]
found that patients who had experienced massive weight loss
required longer, more extensive procedures and had more
wound healing problems, but that the complications more
frequently involved areas other than the arms, when they did
occur (Table 1).
6 Operative Description
Prior to prepping and draping, we begin by injecting 1 %
xylocaine with epinephrine along the anterior longitudinal
marking. Approximately 30 cc per arm is used to then inject
the areas of planned dissection. Incision is made under full
epinephrine effect (Fig. 9). Bovie dissection is used initially
until the muscular fascia is reached. Finger dissection is used
supramuscularly, a plane which is surprisingly loose, and
this maneuver easily separates the tissues to be eliminated
from the underlying muscle fascia. No vital structures are
encountered in this dissection unless the muscle fascia is
inadvertently penetrated. Small vessels and cutaneous nerves
can be easily seen and cauterized from distal to proximal.
The excess “pannus” is fully mobilized before initiating
excision (Fig. 10). Tailor tacking is performed as follows.
The central portion of the pannus is divided gradually in a
vertical direction and the skin from the anterior and posterior
margins are stapled together (Figs. 11 and 12). The tension
and aesthetic tightening are judged by looking and feeling
the circumference of the upper arm. If perceived laxity is
appreciated, the staple is removed and the vertical incision is
lengthened and the edges are stapled together again. This is
repeated by dividing the distal portion of the divided pannus
Brachioplasty
Table 1 History of the procedure Author
Posse [22]
Correa-Itturaspe and
Fernandez [6]
Pitanguy [23]
Clarkson and Jeff [24]
Franco and Rebello [25]
Juri et al. [7]
Borges [8]
Regnault [16]
Hallock and Altobelli [17]
Goddio [9]
Lockwood [10]
Marquez and Abramo [26]
Teimourian [27]
Pinto et al. [11]
Strauch et al. [4]
again into two portions. A line is drawn between the inter-
vening segments and they are excised with scalpel and Bovie.
Staples are removed and the edges are stapled approximated
by advancing the inferior or dorsal skin edge towards the
axilla (Figs. 13, 14, and 15). The same tailor tacking is
employed once again with the proximal remaining pannus
and redundant skin is excised. The dog ear is worked out
along the right angle incision in the axilla. Meticulous hemo-
stasis is important but easily accomplished because of the
epinephrine-induced vasoconstriction. Liposuction of the
proximal forearm adiposity juxtaposed to the elbow is then
performed (Fig. 16). We use 10 cc of the xylocaine/epineph-
rine into that area 10 min before initiating liposuction to
avoid overdistention and maximize the ability to recognize
the optimal contours in that area. Avoidance of the ulnar
nerve by staying in the superficial tissues is important to pre-
vent neuropraxic injury.
Wound closure is completed using Quill or Covidien V-loc
sutures (Fig. 17). The operative time has decreased by one
third or more by using this system. #1 Quill deep subcutane-
ous suture approximates the soft tissues followed by 2–0
Quill subcuticular running suture. Just prior to final sutures
are placed at proximal and distal wound margins, a #10
Jackson-Pratt drain is placed by taking a long 3 mm liposuc-
tion cannula and introducing it through an axillary stab inci-
sion. The cannula is then advanced subcutaneously to the
distal end of the wound. The end of the JP drain tubing is
pushed onto the tip of the cannula and with suction attached
to the tube (to help keep it temporarily fixed to the cannula) is
pulled attached to the cannula through from the distal edge of
the incision through to the axilla (Fig. 18). The drain is placed
at this stage to avoid the tedious annoyance of the drain pok-
ing out of the wound as it is closed. Dermabond is applied
437
Year Contribution
1943 Elliptical incision
1954 Aesthetic brachioplasty technique
First published
1975 Curvilinear S-type incision
1966 Supra- and infrascapular incisions
1977 L-shaped incision
1979 T-flap and quadrangular closure
1982 W-plasty incision
1983 Combined brachioplasty, axilloplasty, and pre-axilloplasty
1985 Combined brachioplasty, thoracoplasty, and mammaplasty
1989 Deepithelialized posterior flap and creation of bicipital
sulcus
1995 Suspension via the superficial fascial system
1996 Treatment of brachial, axillary, and elbow segments
1987 Classification of the deformity/patients
2000 Use of molds for brachioplasty
2004 Altered Pitanguy’s sinusoidal scar, posterior to the medical
biccipital sulcus
finally and then Medipore tape placed along the entire length
perpendicular to the wound edge to eliminate tension. The
closed incision, with drain in place, is shown (Fig. 19).
7 Peri- and Postoperative Care
The postoperative inflammatory response, edema, and
ecchymosis seen in brachioplasty can be modulated to a cer-
tain extent. Pain control requirements tend to be minimal and
include mild narcotics initially and nonsteroidal anti-
inflammatory medications. Gentle compressive forces are
provided to prevent fluid collection: an elasticized garment is
worn for at least a month postoperatively and Medipore tap-
ing continues for 3–4 months until the scar is mature.
Because of the necessity of this taping and garment wear,
patients are advised to wait until cool weather months of the
fall and winter to have this surgery performed, if possible.
Patients return to light work in 1 week but are advised to
abstain from upper-body exercise for 2 months.
8 Avoidance of Complications
Brachioplasty represents a challenge for many surgeons and
has historically had a high complication rate. Patient com-
plaints after brachioplasty typically involve scars that are
malpositioned, broad, or hypertrophic. Wound dehiscence
or necrosis of the flap edges may occur, and post-massive
weight loss patients may be slow to heal due to previously
subclinical nutritional deficiencies. Shermak et al. [18] pub-
lished a seroma incidence rate of 14 % in their large series,
which is comparable to those rates in panniculectomy or belt
438
lipectomy patients. The authors found that skin-excision
weight correlated with seroma rate and that each additional
pound of skin excised correlated with an increase in the
seroma rate of 9 % [18]. As in other body contouring proce-
dures, the risk for seroma can be decreased with limitation
of undermining and placement of drains. If the tissues are
not contoured symmetrically, contour irregularities includ-
ing depressions or folding of excess remaining tissues could
result. Contour irregularities, if they do occur, are often due
to overcorrection centrally or underresection proximally and
distally [3, 19]. The reported scar revision rate after brachio-
plasty is 10 % in some series [19], and this is an area of noto-
riously poorly aesthetic scarring. Nerve injury, major wound
complications, and lymphedema are potential complications,
but have not been observed. When liposuction is employed,
Fig. 1 Preoperative posterior view of a 48 year-old female patient
requesting brachioplasty for upper arm laxity/redundant tissue
Fig. 2 Preoperative appearance of the patient’s right medial arm
R.J. Zienowicz and E.A. Hoy
ultrasound-assisted lipoaspiration is avoided at the medial
elbow due to the nearby course of the ulnar nerve.
9 Results/Cases
The following example is a 48-year-old female who under-
went bilateral brachioplasty. Her preoperative anterior, pos-
terior, and lateral views are shown (Figs. 1, 2, 3, 4, 5, 6, and 7).
The intraoperative views are shown in Figs. 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, and 18 and the postoperative results shown
in Fig. 19, demonstrating mild widening of the scar but a
very aesthetic appearance to the upper arm with resolution of
the excessive posterior curvature of the arm. She is shown at
her 20-week follow-up appointment.
Fig. 3 Preoperative appearance of the patient’s left medial arm
Fig. 4 Preoperative appearance of the patient’s abducted right lateral
arm, showing laxity and soft-tissue redundancy
Brachioplasty 439

Fig. 5 Preoperative appearance of the patient’s abducted left lateral

arm, showing laxity and soft-tissue redundancy

Fig. 7 Preoperative, true-lateral view of the patient’s left arm in repose

Fig. 6 Preoperative, true-lateral view of the patient’s right arm in Fig. 8 Intraoperative view, the posteriolaterally based flap is elevated
repose superficial to the deep investing fascia of the arm
440 R.J. Zienowicz and E.A. Hoy

Fig. 9 Appearance of the flap when fully elevated, based

posteriolaterally

Fig. 11 Here the flap has been tailor-tacked, and the excess tissues
incised

Fig. 12 With excess tissue removed, the portions of the incision

Fig. 10 The elevated flap is marked to delineate the extent of tissue to between tailor-tacks are sequentially closed
be removed, splitting the flap transversely in the midline
Brachioplasty 441

Fig. 15 Suction-assisted lipectomy is used to reduce the distal dogear,

Fig. 13 The incision is stapled closed, and work proceeds proximally. and to help minimize the length of scar needed to achieve the desired
The tailor-tack technique and timely closure helps prevent overresec- contour
tion and edema, repectively, which can complicate closure

Fig. 16 The author’s preferred approach involves the use of barbed

suture materials to expediate closure and avoid retained suture due to
knots

Fig. 14 The tissues of the axilla are treated similarly, with extension of
the incision onto the trunk if necessary
442
Fig. 17 A long, narrow liposuction cannula facilitates passage of
closed-suction drains beneath the wound closure
Fig. 18 Appearance of patient’s arm at the conclusion of the proce-
dure, with wounds sutured and drains secured
Fig. 19 20 weeks postoperatively illustrating improved contour and
some widening of the surgical scars
R.J. Zienowicz and E.A. Hoy
10 Futures and Controversies
Some authors advocate staging the definitive brachioplasty with
an initial session of liposuction. The liposuction is performed 3–5
months prior to the brachioplasty to reduce the excess subcutane-
ous fat: this is argued to maintain the skin’s elastic recoil proper-
ties and reduces the extent of dissection [19]. Other approaches
utilizing a short scar have been described to deal with less exten-
sive deformities of the upper arm and employ selective liposuc-
tion of key areas [20]. Increasingly, brachioplasty modifications
are being proposed which are both tailored to the deformity and
to patient expectations for scarring postoperatively [21].
References
1. Glanz S, Gonzalez-Ulloa M (1981) Aesthetic surgery of the arm:
part I. Aesthetic Plast Surg 5:1–17
2. Pitman GH (1997) Liposuction and body contouring. In: Aston SJ,
Beasley RW, Thorne CHM (eds) Grabb and Smith’s plastic surgery,
5th edn. Lippincott-Raven Publishers, Philadelphia
3. Guerrerosantos J (1979) Brachioplasty. Aesthetic Plast Surg 3:1
4. Strauch B, Greenspun D, Levine J, Baum T (2004) A technique of
brachioplasty. Plast Reconstr Surg 113:1044–1048
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to upper arm contouring. Plast Reconstr Surg 118:237–246
6. Correa-Iturraspe M, Fernandez JC (1954) Dermolipectomia bra-
quial. Prensa Med Argent 34:2432–2436
7. Juri J, Juri C, Elias JC (1979) Arm dermolipectomy with a quadran-
gular flap and “T” closure. Plast Reconstr Surg 64:521–525
8. Borges AF (1982) W-plastic dermolipectomy to correct “batwing”
deformity. Ann Plast Surg 9:498–501
9. Goddio AS (1988) A new technique for brachioplasty. Plast
Reconstr Surg 84:85–91
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suspension. Plast Reconstr Surg 96:912–920
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HAP, Amaral AG (2000) Brachioplasty technique with the use of
molds. Plast Reconstr Surg 105:1854–1860
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approach to correct excess tissue of the upper arm, axilla, and lat-
eral chest. Plast Reconstr Surg 117:403–411
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massive weight loss. Aesthetic Plast Surg 26:76–84
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itant procedures after massive weight loss: a statistical analysis
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15. Soliman S, Rotemberg SC, Pace D, Bark A, Mansur A, Cram A,
Aly A (2008) Upper body lift. Clin Plast Surg 35:107–114
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Aesthetic Plast Surg 7:31–36
17. Hallock GG, Altobelli JA (1985) Simultaneous brachioplasty, tho-
racoplasty, and mammaplasty. Aesthetic Plast Surg 9:233–235
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ment following body contouring surgery for massive weight loss: patient
risk factors and treatment strategies. Plast Reconstr Surg 122:280–288
19. Cannistra C, Valero R, Benelli C, Marmuse JP (2007) Brachioplasty
after massive weight loss: an algorithm for the surgical plane.
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plasty: technical refinements in upper arm contouring. Plast
Reconstr Surg 121:305–307
Brachioplasty
21. Citarella ER, Conde-Green A, Nakamura F, Pitanguy I (2010)
Plication of the brachial fascia: an important step in dermolipec-
tomy procedures of the arm. Aesthetic Plast Surg 30:66–70
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and inner side of the arm and elbow. Clin Plast Surg 2:477
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surgery, vol 2. Butterworth-Heinemann, Oxford, p 315
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Surg 102:545
 Hand Rejuvenation
Cristina Spalvieri and Francesco Brunelli
1 Introduction
The hand is the organ responding to human desire, through
which we experience and come into contact with the external
world. Together with the face, it is the most exposed part of
the body. Because of its development and mobility, and the
perfect sensibility of its teguments, the hand represents a
highly sensitive organ of touch.
Humans use hands to a much higher degree of perfection
than any other animal. Therefore, we can assert that man is
morphologically superior to animals thanks to both the hand
and cerebral activity.
This chapter outlines hand rejuvenation as a branch of
surgery starting with the treatment of malformations, further
describing posttraumatic and oncologic reconstruction
techniques, and finally aesthetic treatment of the hand after
damage caused by its use and radiation exposure.
Hand surgery first emerged as a branch of surgery a
century ago, when through unifying several specialist
corroborations this new discipline accurately described
lesions, pathologies, and aesthetic features of the hand [1]
Development of plastic, reconstructive, and aesthetic sur-
gery of the hand seems to run parallel to human evolution as
a human, philosophic, and social entity. Studies of anatomy,
orthopedics, neurosurgery, plastic surgery, and rehabilitation
promote functionality and the “aesthetic” as foremost in
reconstructive techniques of the hand. Throughout the ages
poets, painters, and sculptors have celebrated and portrayed
the power and delicacy of the hand. In surgical fields aimed
at perfection and of expertise, the demand for treatment of
aging-related aesthetic damage [2] is becoming increasingly
C. Spalvieri, MD (*)
Dipartimento di Dermatologia e Chirurgia Plastica,
Università di Roma “Sapienza”, Roma, Italy
e-mail: cristina.spalvieri@fastwebnet.it
F. Brunelli, MD
Chirurgien orthopediste, Clinique Jouvenet, Institut de la Main,
Paris, France
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_31
more frequent. Hands reveal aging and show our life history.
Techniques used for treatment of the aging face were first
experimented with and finally applied to the hand. Synergy
between medical, surgical, and dermatologic techniques has
permitted the development of hand rejuvenation techniques.
2 Embryology
At the beginning of the fifth week of gestation, the limb buds
become visible, presenting in a “paddle” shape. Initially they
consist of a mesenchymal axis covered by an ectodermal
layer. At the sixth week the bud apical ridge becomes flat and
is separated from the more cylindrical proximal segment
through a circular constriction.
Contemporaneous small radial incisures at the distal edge
of the bud and a second furrow, separating the proximal bud
into two segments, take shape; thus three definitive seg-
ments, which form the extremities, are visible. At the sixth
week, the cartilaginous framework may be recognized.
Eendochondral ossification begins at the end of the embryo-
nal development. The first ossification centers appear at the
edges of the long bones at the 12th week of development. From
the center of primary ossification, the endochondral ossifica-
tion progresses toward the edges of the cartilaginous structure.
At birth the diaphysis is completely ossified, whereas the
epiphyses are cartilaginous. A temporary cartilaginous tissue
named the epiphyseal plate, important for growth and bone
length, remains within both the diaphyseal and epiphyseal
ossification centers.
The tegumentary apparatus, together with its annexes as
hair follicles, nails, and glands, begins from the ectodermal
ridge. Melanocytes, responsible for the skin color, derive
from the neural crest and migrate into the skin. New cell
production ensues in the stratum germinativum. The dermis
originates from the mesodermis. Hair develops from the cell
proliferations of the underlying dermis. Sebaceous and
sudoriferous glands derive from the epidermal layers [3].
445
446 C. Spalvieri and F. Brunelli

3 Anatomy and Physiology of Aging

The hand represents the ending extremity of the upper limb

and ends with five free appendages named fingers. It can be
divided into two regions: palmar and dorsal. The hand is
made of several tissues, the most superficial of which is the
skin.
The skin, or tegumentary apparatus, consists of a dynamic
variety of tissues and covers the body completely. It provides
protection for the body and separates it from the external
environment, finally connecting it with the inner tissues. The
skin is the largest organ of the human body. In adulthood, it
has a mean surface of about 1.8 m2 and a weight of 16 % of
the whole organism. It varies greatly in thickness from 0.5 to
4 mm, depending on the sex and the different sites of the
body surface.
The color of skin, changing with the race, depends essen-
tially on three components: the yellow one of the corneous
layer (keratin), the dark component of the epidermis (mela-
nin), and the red constituent of the microcirculation (hemo-
globin). Skin is composed of three anatomic-functional
overlapping layers: the superficial one that named the epider-
mis, the intermediate layer called the dermis, and the deeper
layer named the hypodermis or subcutaneous tissue.
The palmar skin is completely free of hair and sebaceous
glands, whereas it contains a high proportion of sudoriferous
glands. Generally skin thickness is consistent but depends on
genetics and professional activity. Under the skin, the subcu-
taneous tissue has a particular cellular structure; the connec-
tive tissue contains numerous vertical fibers that tightly bind
the deeper dermis with the aponeurosis, circumscribing a Fig. 1 Anatomic aspect of the dorsum of the hand
lodge system or cavities filled with adipose lobules. The
major development of adipose tissue is observed at level of The connective subcutaneous tissue almost totally lacks
the metacarpophalangeal joints. In this region, the adipose adipose tissue. It has a lamellar structure and forms a
tissue connects with the subcutaneous tissue of the dorsal superficial fascia, which is proximally continuous with the
surface, with the deeper connective tissue allowing the pas- fascia of the wrist, and distally with the subcutaneous tissue
sage of the vessels and digital nerves through the palmar of the palmar region into the interdigital spaces.
aponeurosis spaces. Under the skin and the subcutaneous tis- The superficial fascia is a white fibrous lamina where
sue is the superficial palmar fascia. The palmar aponeurosis superficial vessels and nerves run, beneath which the follow-
is connected with the skin by numerous vertical bundles, ing structures develop: a layer of tendons, the deeper dorsal
especially in the palmar distal portion and in correspondence fascia, the interosseous, and the skeletal system (Fig. 1) [4].
with skin furrows. Skin aging is the process through which our organism
The subfascial layer develops under the palmar fascia. It shows the signs of the changes attributable to the passage of
consists of hand muscles and tendons, vessels, and nerves time. In fact, skin is the organ most susceptible to visible
disposed in several compartments, the interosseous layer aging. Skin aging is determined by genetic or biological and
composed of muscles, vessels, and nerves, and finally the environmental factors. In contrast to the environmental fac-
bone layer. tors, the genetic ones remain constant throughout life. They
The dorsal region of the hand consists of all the soft tis- act as a “biological watch” signaling the aging of the all
sues disposing dorsally with respect to the distal bone struc- human cells. Skin aging originating from genetic factors
ture of carpus and five metacarpals. In contrast to the palmar begins very slowly after 25 years of age, with a great
skin, the dorsal skin is thin, very movable with the underly- subjective variability, and becomes visible after 40 years of
ing layers, and contains hair and sebaceous glands. age. Environmental factors notably influence skin aging:
At full extension, the hand presents many transversal among the external agents to consider are ultraviolet (UV)
folds, more visible during extension movements of fingers. radiation, adverse climatic conditions (such as hot, cold,
Hand Rejuvenation
Fig. 2 Anatomic aspect of the palm of the hand
wind), alcohol consumption, smoking, and hormonal
modifications (i.e., thyroidal pathology, menopause, andro-
pause). All of them inevitably generate a transformation of
our tegumentary apparatus. It is certain that UV radiation
plays an important role in accelerating the skin-aging pro-
cess. UV-induced photodamage, and especially the damage
due to radiation emitted by artificial sunlight, increases in
proportion with exposure time. Moreover, skin has a “solar
memory” responsible for damage increasing year by year.
The damage reduces or is less visible when skin is not
exposed to the sun. The sum of this damage results in photo-
aging, a process that is superimposed upon intrinsic aging
and becomes evident through the typical aging signs such as
wrinkles and dark flecks. In fact as years pass, the skin tonic-
ity and elasticity decrease progressively, with the skin further
appearing pale, thin, dry, and with fine wrinkles.
These aging signs represent the more visible consequence
of cutaneous atrophy and are directly correlated with the
reduction of collagen and elastic fibers of the dermis.
Photoaging, well studied and documented from both
microscopic and molecular points of view, derives from the
447
Fig. 3 The dorsum of the hand of a 75-year-old patient with typical
actinic damage and thinning of the cutaneous layers
cumulative action of UV radiations. It is clinically
characterized by cutaneous linear accentuation of the
corneous layer, sallow and dry skin, wrinkles, dyschromias,
dyskeratosis, and lack of tone. Microscopically, aging
observed in non-sun-exposed skin is consequent to the reduc-
tion of vascular network (cutaneous pallor), reduction of the
glandular component (dryness), flattening of dermal-epider-
mal junction, and reduction in the extracellular matrix of
dermis, glycosaminoglycans, collagen, and elastic fibers
(cutaneous atrophy and tissue laxity).
Histologic changes associated with photoaging are preva-
lently hyperkeratosis, epidermal atrophy, and an increasing
number and dimension of melanocytes with irregular disper-
sion of melanin.
In the epidermis the reduction in Langerhans cells may
account for deficiency of the immune response and the
increasing risk of development of cutaneous tumors (basal
cell and squamous cell carcinoma) in the aged skin. Dermis
shows an increase in degenerated elastic fibers (solar elasto-
sis), reduction in collagen and glycosaminoglycans produc-
tion, and vascular network alterations.
Hand anatomy differs between the dorsal (Fig. 1) and pal-
mar regions (Fig. 2). In fact aging involves both surfaces, but
above all the dorsal one, which is more exposed and ana-
tomically predisposed (cutaneous thin layers, poor subcuta-
neous tissue, major exposition to environmental agents)
(Fig. 3).
448 C. Spalvieri and F. Brunelli

4 Techniques

As applies to the rest of the body, the aging hand is affected

by both genetic and environmental factors (photoexposure,
climatic and toxic external agents).
In the last years, cutaneous rejuvenation techniques have
found many solutions to correct simultaneously the several
factors responsible for aging. For hand aging in particular,
many photorejuvenation techniques have been proposed,
such as pulsed light, radiofrequency, cutaneous biostimula-
tion, injection of autologous and heterologous materials for
remodeling and filling, and chemical peels. Since the aging-
related hand defects are variable in number and of varying
nature, the techniques are numerous and each one has spe-
cific limitations and indications.
Photoaging using laser (photorejuvenation) or pulsed
light at high intensity aims to eliminate from the face skin (or
hands, neck, and décolleté) the signs of phototoxic and aging
factors such as age spots, solar lentigines, rosacea, enlarged
pores, and fine superficial wrinkles.
Photorejuvenation exploits a laser energy beam or pulsed
light at high intensity, shooting selectively all the cutaneous
benign pigmentations, thus eliminating them progressively
and stimulating new collagen formation. The skin to be
treated must be as fair as possible, since the light ray targets
the melanin and the dark component of the lesion (rosacea,
cutaneous freckles, hyperpigmentations, hyperkeratosis).
The operator, after a correct evaluation of indication and an
accurate anamnesis, must apply on the zone to be treated a
transparent gel that carries the light beam to the lesion, thus Fig. 4 Photorejuvenation with pulsed light 24 h after treatment. Visible
is the cutaneous irritation and erythema of the hyperpigmented lesions
avoiding thermal damage. The pulses are established on the
basis of the areas to be treated and the type of aesthetic defect
to be eliminated. This technique allows one to selectively
treat the defect without damaging the surrounding tissue,
according to the selective photothermolysis principles.
The laser applications must be repeated at intervals of 1
month until the defect disappears (generally after 3–6 ses-
sions). After treatment the freckles become darker and
slightly erythematous. The cutaneous irritation remains for
about 48 h (Fig. 4).
With photorejuvenation the freckles and the superficial
cosmetic defects of the skin are progressively removed,
definitively and with very satisfactory results.
Major complications consist of superficial burns and
persistent edema, which are often transitory and sporadic
phenomena (Figs. 5 and 6).
This procedure treats the superficial pigmented lesions of
the skin, and is therefore the ideal treatment in association
with deep rejuvenation of collagen using bipolar radiofre-
quency. The electric field produced by a radiofrequency tool
crosses the tissue, thus determining molecular electric charge
modifications according to the Ohm’s law, which states that Fig. 5 The dorsum of the hand of a 73-year-old patient with hyperpig-
the produced heat is directly proportional to the impedance mented lesions before treatment with pulsed light
Hand Rejuvenation
Fig. 6 Results of pulsed light after two sessions
of the crossed tissue. The radiofrequency effect is visible
above all at the level of dermal collagen and the deeper
structures, its main purpose being to improve the tissue laxity
by reducing it.
The heat effect generated in the skin leads to the denatur-
ation of collagen fibers together with their progressive
contraction during the weeks following treatment, and finally
new collagen production attributable to the tissue-repairing
process of the dermis.
Other types of cutaneous stimulations exploiting lasers of
different wavelengths, varying between 532, 585, 1064,
1320, 1450 and 1540 nm, have been proposed to improve
skin tonicity and brightness. Recent studies have described
the association between frequencies of 532 nm KTP laser
followed by 1064 nm Nd:YAG, with optimum results.
For some years skin resurfacing, utilizing both the CO2
and Erbium:YAG lasers, has been the most commonly
employed laser procedure. However, the excessive
expectations of this method, its timing, and the medical
postoperative treatment have reduced its use and patient
selection.
Biorevitalization is a treatment consisting of the injection
of biocompatible substances at the level of the superficial
dermis, with the aim of stimulating, reequilibrating, and
reactivating the dermis. Several materials have been
proposed, such as products based on amino acids (proline,
lysine, glycine, leucine) more or less associated with
reticular/nonreticular hyaluronic acid, DMAE (dimethyl-
aminoethanol), vitamin complexes, low-weight and non-
crossed-linked hyaluronic acid, to be absorbed in a short
time. Almost all the techniques must be performed at inter-
vals of 2 weeks, for about 4–5 applications, and subse-
quently at intervals of 3 and then 4 weeks depending on the
pretreatment clinical examination and the type of results
obtained.
449
Regarding autologous filling materials, lipofilling is
worthy of mention.
The idea of using the fat as a filling material (filler) is not
a recent one. Although some authors state that this concept
began two centuries ago, it was only in 1950 that the first
article on the use of autologous fat (harvested from the
patient) for body contouring [5] was published. Since then
this technique, soon named lipofilling, has been widely per-
formed, albeit with several limitations (above all that there
are no long-lasting results) and some contraindications [6].
The idea of enlarging body areas using the fat that is natu-
rally in excess was so attractive that many surgeons tried to
improve this technique to optimize results in terms of
patients’ satisfaction and duration of correction [7, 8].
In 1998, Sidney Coleman reported the results obtained
with a special technique of preparation and infiltration of
adipose tissue, and named this method “lipostructure” (struc-
tured lipofilling) [9, 10]. As it is derived from lipofilling,
lipostructure may be understood only if the aspects concern-
ing the original operation and the limitations that the new
technique proposes to go beyond are clear.
Fat harvested from the patient and its infiltration or lipo-
filling represents a fat graft. Technically the adipose tissue
is aspirated in zones where it is in excess, using cannulas
connected to syringes and then injected in the area to be
treated.
Since no vascular connection is preserved for grafting, the
transferred tissue can survive in the new site only if it is in
direct contact with a well-vascularized tissue, from which it
will initially receive nutrition through imbibition and subse-
quently from new vascular connections. Lipofilling works
very well when small amounts of fat are infiltrated, in both
well-vascularized tissue and muscle [11].
The first problem of conventional lipofilling that Coleman
has faced and solved was related to the large amount of adi-
pose cells damaged by the aspiration procedure, as the infil-
trated adipocytes did not survive. During lipostructure, the
adipose tissue is collected using very small-diameter syringes
and aspirated at low pressure, centrifuged to separate the adi-
pocytes from the ones damaged and from their by-products.
In this way, the lipostructure allows injection to exclusively
intact cells, capable of surviving in their new site [12].
The second problem to be solved was related to the neces-
sity of allowing direct contact between the infiltrated cells
and well-vascularized tissue. For this purpose, lipostructure
requires that infiltration should be performed in multiple
very small channels, with a needle depositing only small
amounts (less than 1 mL) of adipose tissue in each one [13].
The skin of the dorsum of the hand, very movable and
delicate, becomes thin and irregularly pigmented with aging,
with dark flecks caused by actinic or seborrheic keratosis.
Moreover, the underlying bone becomes exposed, producing
a non-youthful appearance.
450 C. Spalvieri and F. Brunelli

Lipofilling has also been used to correct the “skeletal” aspect

of the hand and the excessive thinning of the skin. The opera-
tion consists of harvesting a small amount of fat from the flanks
and the abdomen, as during a micro-liposuction, and injecting
the collected material into the dorsum of the hand. Local anes-
thesia is obviously requested and, even though the result is soon
visible, more than one treatment may be necessary. The injected
fat, in fact, tends to be reabsorbed, in an unpredictable manner.
According to published clinical studies, 25 % of patients require
a new injection about 1 year after the first treatment.
Over the period of approximately 1 year, repeated fat
injections may be required to achieve a definitive result.
In any event it must be borne in mind that there is no clini-
cal study documenting the results of these treatments over a
sufficiently long period, owing to their recent deployment in
clinical practice.
Peelings and lipofilling, like laser and cryotherapy, are
simple techniques that are easy to perform. Nevertheless,
lasers and chemical peelings have led to severe complica-
tions, with late healing and, in some cases, retracting scars.
Today, body fat can be used as a permanent filler to correct
numerous defects, but there are some limitations due to both
the absolute amount of injectable fat and the type of ana- Fig. 7 Aspect of the dorsum of the hand before photorejuvenation
treatment
tomic sites to be treated [14].
A valid therapeutic complement to the aforementioned
techniques is peeling. The aging process leads to the necessity of a treatment
The application of peeling is progressively increasing in which operates on a dual level, considering the color and the
the light of new technological advances made in the dermal- consistency of the hand tissue on the basis of the patient’s
cosmetology approach to aging. The possibility to use chem- age and demands.
ical agents, variable for consistency and effect (e.g., glycolic In the last years, on the basis of our experience, photore-
acid, retinoic acid, trichloroacetic acid, lactic acid, kojic juvenation and pulsed light at high intensity are our optimal
acid), provides the specialist an efficacious therapeutic tool solutions for the treatment of dyscromias. According to the
to overcome different problems related to skin aging of the principle of selective photothermolysis, the light energy
dorsum of the hand. Regarding peels, both glycolic acid and beam is converted to thermal energy only in the presence of
Retin-A have been demonstrated to reduce pigmentation melanin (contained into the freckle). In this way, dyscromias
efficiently. More aggressive peels such us phenol and the are selectively destroyed in a few sessions and the surround-
pyruvic acid may be theoretically used for their efficacy, but ing tissue is not damaged.
may expose the patient to a very high risk of complications Two or four sessions, performed monthly, are necessary
during the healing process [15]. to efficaciously treat the whole zone, but as early as a few
days after the first session the color will be more homoge-
neous. Moreover, the heat generated by the pulsed light will
5 Authors’ Technique also lead to a modest cutaneous compactness, owing to the
induction of the naturally occurring repair processes (Figs. 7
Hands unmercifully reveal the age and date of birth even in a and 8).
spritely and healthy body. Despite aesthetic face correction, Another problem requiring a more elaborate solution con-
true age will always be revealed by the hands, showing sists in the progressive loss of substance of the hand skin
imperfections in graphic detail. The thin skin of the dorsum structure. With aging, the skin of the hand becomes so thin
of the hand is a delicate part of the body, with regard to both that the vessels, nerves, and bone become evident on each
continuous stimulation due to muscle activity and its con- movement. In this case, the treatment of choice is evaluated
stant photoexposure. The well-known aging signs are typical on the basis of clinical hand aspect.
hyperpigmented flecks and skin thinning, the latter making The fist solution, if aging is limited to the cutaneous
more visible the underlying veins and the bone structure. plane, is one cycle of sessions with radiofrequency to firm
Hand Rejuvenation
Fig. 8 Result of photorejuvenation after three sessions
the skin. Radiofrequency acts at level of the collagen fibers
by emitting, in a controlled manner, heat in the deep dermis.
As the collagen is heated, it denatures and contracts. This
process induces the natural alignment of fibers and supports
the new collagen production.
For a hand rejuvenation program oriented toward both an
immediate result and quality, it is necessary to combine
many techniques.
If the patient desires an immediate visible result, the
approach consists of injection of absorbable materials or
lipofilling; over time, the patient may choose other integra-
tive treatments such as bipolar radiofrequency or polylactic
acid injection to maintain the result. The fat for this type of
filling is harvested from the patient him-/herself, under local
anesthesia, from hidden body areas. The filling effect is
immediately visible, and within weeks hands appear more
smoothed and the visibility of veins, bone, and nerves is
reduced. Polylactic acid injection is a further technique per-
formed to correct volume reduction. Its use is indicated when
the carpus bones are visible through the hand skin. Skin fur-
rows can be filled by a solution of this material.
Since the hand is continuously subject to movements, it
needs not so much a simple “filler” but rather a constant “tis-
sue stimulator.” The polylactic acid is a “dermal stimulator”
451
because it stimulates the skin cells to produce collagen.
Nowadays it is used in the treatment of patients affected with
face lipoatrophy. The material is implanted by injection
using a threading technique in a criss-cross fashion, thus
treating successfully whole atrophic area. The thick dermis
is the natural consequence not so much of the filling action
but rather of the new collagen proliferation. The definitive
results last longer than those obtained with other materials,
and in fact the effect lasts up to 18 months. Today it is pos-
sible to treat the hand aging not by palliative techniques but
via superficial and deep rejuvenation techniques.
Even though hand rejuvenation is not the most requested
treatment in aesthetic surgery, it is desirable for some people
who consider such a body part important from a professional
and social point of view. The rejuvenation techniques that
have been developed aim to correct aging defects, thus giv-
ing the hand a healthy aspect complying with a body in
healthy condition.
The authors have used carboxytherapy as a novel rejuve-
nation technique. Initially this therapy, consisting of subcu-
taneous and cutaneous injection of gaseous carbon dioxide,
was used in aesthetic medicine for cellulite treatment.
Carboxytherapy improves the blood circulation and the cel-
lular metabolism by causing vasodilatation and reactivation
of the microcirculation, thus increasing tissue oxygenation.
Carboxytherapy is generally used for the treatment of the
following cosmetic defects and pathologies:
• Treatment of cellulite
• Treatment of arteriopathy and microcirculatory stasis
(medium venous insufficiency) in angiology
• Treatment of arthrorheumathic pathologies and periar-
thritis in orthopedics
• Wound care
The pressure of gas emission depends on the skin and
aesthetic defect type and the final depth the treatment must
achieve.
The main effects are due to:
• Arterial vasodilatation
• Circulation improvement
• Tissue oxygenation
The treatment is performed in ambulation, without
recovery time. Treatment consists of microinjections, with
very thin needles [16], at variable doses, in different points
of the area to be treated [1].
Treatment generally requires one session per week and
about 12–15 sessions in total. The treatment lasts on average
of 15–20 min, and the return to daily activities is
immediate.
452
Fig. 9 The dorsum of the hand of a 62-year-old patient before
carboxytherapy
Fig. 10 Result of carboxytherapy after four sessions
The carboxytherapy can be combined with other treat-
ments such us pulsed light, lasers, chemical peels, and other
techniques, to obtain a final optimal result. In these cases,
carboxytherapy can also optimize the other treatment effects
(Figs. 9 and 10).
6 Complications
The most frequent observed complications vary in relation to
the single chosen treatment. Peeling can lead to transient or
persistent erythema, which can last for 48–72 h.
Filler injections and biostimulation rarely have side
effects such as allergic reactions, granulomas, and hemato-
mas. It should be noted that these techniques are contraindi-
cated in cases of allergy for the injected material, pregnancy,
C. Spalvieri and F. Brunelli
coagulation dysfunctions, active herpes, and dermatologic
autoimmune pathologies.
Radiofrequency can lead to complications such as ery-
thema, edema, and sensibility alterations. The most frequent
complications occurring with the use of laser are intensive
erythema, transient edema, and, in the more severe cases,
superficial burns, which rarely develop evident scars.
Carboxytherapy can be responsible for ecchymosis and
transient tumefaction of the tissue, disappearing after some
hours.
Peeling and lipofilling, laser therapy, and cryotherapy are
extremely simple techniques that are easy to perform. Laser
and peeling applied on the dorsum of the hand can lead to
severe complications, demonstrating extremely delayed
healing processes and retracting scars in some cases. In aes-
thetic medicine, as in plastic surgery, a detailed anamnesis,
an accurate objective examination, and a correct indication
regarding the patient’s expectations lead to an effective
treatment with a lower complication rate.
References
1. Brunelli G (2004) Manuale di chirurgia della mano. Edizioni
Micom srl, Milano
2. Scuderi N (2006) Un Elogio all’imperfezione. Editori Riuniti,
Roma
3. Langman (1986) Embriologia medica, IV Edizione italiana. Edito
Piccin Nuova Libraria S.p.A., Padova, pp 133–137
4. Testut L, Jacob O (1998) Trattato di anatomia topografica. Utet,
Ristampa, Torino, Italy
5. Peer LA (1950) Loss of weight and volume in human fat grafts.
Plast Reconstr Surg 5:217
6. Peer LA (1956) The neglected free fat graft. Plast Reconstr Surg
18:233–250
7. Billings E Jr, May JW Jr (1989) Historical review and present status
of free fat graft autotransplantation in plastic and reconstructive
surgery. Plast Reconstr Surg 83:368–381
8. Nguyen A, Pasyk KA, Bouvier TN, Hassett CA, Argenta LC (1990)
Comparative study of survival of autologous adipose tissue taken
and transplanted by different techniques. Plast Reconstr Surg
85:387–389
9. Coleman SR (1997) Facial recontouring with lipostructure. Clin
Plast Surg 24(2):347–367
10. Coleman SR (1998) Facial reconstruction with lipostructure.
Presented at Horizons in plastic surgery, American Society for
Aesthetic Plastic Surgery, La Jolla, CA USA
11. Ellenbogen R (2000) Fat transfer: current use in practice. Clin Plast
Surg 27(4):545–556
12. Coleman SR (2006) Structural fat grafting: more than a permanent
filler. Plast Reconstr Surg 118(3 Suppl):108S–120S
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controlled demonstrations. Aesthetic Plast Surg 19:421–425
14. Guerrerosantos J (2000) Long-term outcome of autologous fat
transplantation in aesthetic facial recontouring: sixteen years of
experience with 1936 cases. Clin Plast Surg 27(4):515–543
15. Gutu V, Carboni GP (2009) La medicina estetica. Salus
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 Medial Dermolipectomy of the Thigh
Flavio Saccomanno
1 Introduction
Flaccidity of the medial region of the thighs, with or without
lipodystrophy, causes considerable inconvenience for those
women affected by it. This aesthetic defect almost exclu-
sively affects women and is uncommon in men except in
cases of intense and repeated weight loss. In rhizomelic obe-
sity of the lower limbs, functionality is the main problem,
where the thighs rub together at the proximal portion. In
extreme cases this can lead to significant skin lesions, con-
siderably limiting the patient’s quality of life. Increased
focus on the problem of obesity by national health organiza-
tions has increased the demand for the correction of excess
skin resulting from significant weight loss.
Dermolipectomy of the medial region of the thighs is
indicated as the preferred corrective surgery. It can be com-
bined with liposuction when, in addition to flaccidity, lipo-
dystrophy is also present, especially in cases of obesity of the
superomedial region of the lower limbs (Fig. 1a, b).
The correction of these abnormalities has never been
viewed with enthusiasm by surgeons because of difficulties
arising from the awkward position taken by the surgeon dur-
ing the procedure in addition to the high risk of complica-
tions: migration of scars, flattening of the inguino-cruro-gluteal
(ICG) sulcus, stretching of the labia majora, distortion of the
buttock, and lateral asymmetry of both form and volume
(Fig. 2).
The medical literature and research publications regard-
ing this issue are scarce. In 1957, Lewis [1] first conceived
correction of “ptosis of the thighs,” describing the “thigh
lift,” whereby he proposed the excision of a large ellipse of
skin and subcutaneous tissue from the anterior inguinocrural
area and another posteromedial ellipse, in a vertical direction
toward the knee, using a minimal, conservative skin dissec-
F. Saccomanno, MD
Private Practice, Rome, Italy
e-mail: flaviosac@tin.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_32
tion. Care was taken to avoid the femoral vessels in the groin
and damage to the saphenous vein. In 1964, Pitanguy [2]
included the inguinocrural area in the trochanteric region by
harvesting a single flap whose superoposterior rotation cor-
rected the trochanteric lipodystrophy in addition to the flac-
cidity of the anterior and medial areas of the thigh. In 1972,
Ducourtioux [3], stressing the importance of gynecological
positioning during surgery, indicated a skin-fat excess in a
vertical direction that could be corrected by horizontal exci-
sion, and a skin excess in an anteroposterior direction that
could be corrected by circumferential excision (vertical
scar). I should also cite Vilain and Dardour [4] who, in their
work of 1975, despite not having made a substantial contri-
bution to the surgical technique, was the first to focus atten-
tion on the fat, describing two types without sufficiently
specifying the topography. They described a “subcutaneous”
fat, which varies with diet, and another, non-localized fat,
“not different from the point of view of the pathologist,”
which does not undergo changes attributable to eating habits.
They described the use of the curette for the correction of
lipodystrophy of the knees. Therefore, Vilain and Dardour
can be placed between the precursors of liposuction and the
study of what is now considered “system fat.” In addition, he
questioned the term “lipodystrophy” (literally, “abnormal
fat”), used to describe localized fat deposits, preferring the
term “steatomeria” (steato = fat, meria = area). Also in 1975,
Hoffman and Simon [5], in classifying patients presenting
indications for the thigh lift into five types, were the first to
focus attention on the complications and their frequency in
this type of intervention: from asymmetry to depression, up
to scar retraction with distortion of the labia majora, and pain
when sitting, even after a period of 3 years.
In 1981, Baroudi and Carvalho [6] described their method
of correction and, despite devoting special attention to the
suture, concluded that it is appropriate to take into account
the possibility of scar revision 1 year after surgery, and to
consider scar migration as a nearly constant result.
In 1984, Regnault and Daniel [7] published a work on the
prevention and treatment of these complications.
453
454
a b
Fig. 1 (a) Excess skin secondary to significant weight loss. (b) Case of rhizomelic obesity
Fig. 2 Downward displacement of the scar and the stretching of the
labia majora when the patient spreads the legs apart
From the first authors who initially described the correc-
tive surgical techniques focusing on the location, extent, and
quality of scars, we progressed to a later stage where studies
focused more on fixing the skin flaps to more rigid structures
to improve the stability of the scars in the inguino-cruro-
gluteal (IGC) sulcus, thus avoiding complications. The fol-
lowing are some works grouped according to the type of flap
fixing and chronology:
F. Saccomanno
• Dermo-adipose fixing: 1973 Delerm and Girotteau [8],
1974 Guerrerosantos [9], 1977 Agris [10]
• Dermo-periosteal fixing: 1982 Temourian and Adham
[11], oriented mainly to the lateral region, fixing the flap
to the iliac crest, with the possibility of extension before
attaching the dermis to the inguinal ligament
• Dermo-fascial fixing: 1988 Lockwood [12]: includes
suturing the perineal flap and the inferior flap with their
subdermal layers, fixing both to the Colles fascia
• Fascia lata–inguinal ligament and periosteum of the
pubic tubercle and ischial branch fixing: 1989 Hodgkinson
[13]; the fascia of the gracilis and adductor muscles is
incised horizontally and dissected from the underlying
muscles, harvesting a fasciocutaneous flap where the
excess skin is resected, and the fascia, overlapping the
superior one, is fixed with a fasciofascial mattress suture
• Dermo-periosteal fixing: 1999 Saccomanno [15]: the bot-
tom flap, including the subcutaneous tissue, fascia super-
ficialis, and the deep dermis, is anchored with four stitches
to the periosteum, from the pubic tubercle to the ischial
ramus. Subsequently the upper flap is sutured to the lower
one in layers
The introduction of liposuction in 1980 by Illouz [16] made
major contributions to the correction of localized adiposity. In
cases of moderate flaccidity associated with lipodystrophy, with
Medial Dermolipectomy of the Thigh 455

the superficial liposuction proposed in 1989 by Gasperoni et al.
[17], in 1990 by Gasparotti [18], and in 1996 by Souza Pinto
et al. [19], with the suction of subdermal fat it is possible to
obtain, in addition to the reduction in volume, a certain degree
of skin retraction. This reduces the degree of flaccidity within
acceptable limits, reevaluating the indication for dermolipec-
tomy to the correction of cases with more severe skin flaccidity.
In the presence of higher degrees of flaccidity, this can only be
resolved with excision of skin excess. In the following years,
there was no significant development in surgical technique until
2004, when Le Louarn and Pascal [20] proposed a more aggres-
sive liposuction technique in the areas intended for resection.
This technique permits a reduction in the thickness of the flaps
while preserving vascularization and the integrity of lymphatic
vessels that are not involved in the skin dissection because of
their subdermal location. Only excess skin (epidermis and der-
mis) is resected, reducing the morbidity of surgery.
In cases of large cutaneous excess and/or obesity, the
manipulation of the flaps and the assessment of the amount of
tissue to be resected are not easy. It is of fundamental impor-
tance to plan the location of the incisions, the extent of skin
dissection, and the packaging, orientation, and anchorage of
the flaps. The final location, the quality of scars, and the sym-
metry of the thighs depend on these factors. To this end, in
1989 Saccomanno et al. [21] presented a technique which pro-
vides at each stage of surgery the systematic standardization of
well-defined and reproducible parameters that facilitate
manipulation of the flaps and the assessment of the amount of
excess tissue to be resected, stressing the importance of the
orientation of the skin flaps in maintaining the aesthetic unity
of the region. The technique is indicated for the correction of
skin flaccidity at all levels, from rhizomelic obesity to second-
ary deformity, and can be combined with liposuction.
2 Classification
In general, two types of patients must be identified: one in
whom the surgical indication is functional, for example, cor-
recting the rubbing between the thighs; and the other, in
whom it is aesthetic: for example, to correct flaccidity of the
skin tone of the medial region of the thighs. Obviously, both
require the same care and precision in technical precautions,
but the objectives are different. A scar that over time migrates
below the sulcus may be acceptable as a functional indica-
tion but is unacceptable as an aesthetic indication. The qual-
ity of the result does not only depend on the surgical
technique or on the tissues but also on the patient’s behavior
in the postoperative period, and this must be taken into
account during the consultation and informed consent.
Regardless of the type of surgical indication (functional
or cosmetic), depending on the predominance of the altera-
tion to be corrected, the thighs can be divided into three basic
groups: with lipodystrophy/obesity, with flaccidity, and with
secondary deformities; and without consideration of the
cause: age, weight loss, or primary surgery (Table 1).

Table 1 Classification and surgical procedure

Functional or Aesthetics

Proximal

1. Lipodistrophy/obesity Toned or Liposuction if flaccidity is present, see ''2''

flaccid
Diffuse

Proximal Lifting (incision in the ICG sulcus) Tonification

(skin
2. Skin flaccidity
flaccidity)
Diffuse Lifting + circumferential dermolipectomy ('T'
shape incision in the ICG sulcus and vertical)
Reduction
(lipodistrophy/
obesity)

3. Secondary deformity One of the above procedures

456
a b
Fig. 3 First surgical phase (a) of lifting for the correction of proximal
flaccidity with incision in the ICG sulcus to be completed, if necessary,
in a second phase (b) of circumferential reduction/tonification with a
Both obese and flaccid thighs may present a proximal or
diffuse deformity. In turn, the thigh with lipodystrophy/obe-
sity may be toned or flaccid.
The tonic lipodystrophic/obese thighs, with both proxi-
mal and diffuse lipodystrophy, are treated with liposuction.
In cases where there is flaccidity associated or not with
adiposity, however, the correction always involves a dermoli-
pectomy, with the only surgical phase being lifting for the
correction of proximal flaccidity. This is supplemented by a
second phase of circumferential reduction/tonification in the
case of diffused flaccidity. The same strategy is used to treat
any type of alteration, regardless of the entity, including sec-
ondary deformities (Fig. 3).
3 Planning and Surgical Technique
Planning and technique consist of four steps that must be
strictly adhered to:
1. Planning
2. Dermolipectomy
3. Fixing the flap
4. Postoperative care
3.1 Planning
The patient must also be well informed on the technical
aspects of the intervention, such as the fixing of the flaps, the
positioning of scars, and their evolution over time. The patient
should be aware that the end result of the scars also depends
on her cooperation in the postoperative phase. She, therefore,
is an active element and an integral part of planning. In addition
to routine preoperative tests and precautions, the surgeon
F. Saccomanno
“T” incision (in the ICG sulcus and vertical in the medial fascia of the
thighs) in the case of diffuse flaccidity
must make a careful assessment of patients who have
undergone severe weight loss, the obese, and cases of com-
bined procedures. When a circumferential reduction is also
foreseen, it is imperative to study the venous system, and pro-
phylaxis is recommended for deep vein thrombosis (DVT).
The dermolipectomy may be combined with saphenectomy.
It is not advisable to combine the thigh lift with abdomino-
plasty, because of both the increase in morbidity and the awk-
ward posturing required by the surgeon during the procedure.
It is also discouraged for the patient in the postoperative
period. Should the decision be made to combine these proce-
dures, abdominoplasty should be performed first, because of
the patient’s position on the surgical table. Abdominoplasty, in
and of itself, repositions the pubis and the skin overlying the
inguinal sulcus by lifting them up. In the author’s opinion, the
incisions at the level of inguinal sulcus in the thighs should be
separate from the suprapubic incision of the abdomen, so as to
maintain distinct aesthetic units of the individual regions and
therefore produce a natural appearance.
Should body contouring, including the aforementioned
interventions, be planned in two deferred procedures, it is
advisable to begin with the abdominoplasty for the reasons
described.
3.1.1 Preoperative Design
With the patient in a standing position, the line of incision in
the ICG sulcus is traced with an indelible dermographic pen.
At the inguinal level, this line can be directed toward the
pubis or externally along the sulcus if the intention is to also
improve the anterosuperior region of the thigh. At the gluteal
level, the line must include the inner third of the sulcus. In
patients with a small labia majora, the incision line should be
positioned about 1 cm lower than the ICG sulcus if the inten-
tion is to increase the height (Fig. 4).
The transition point between crural and gluteal areas is
referred to as “a” and that of greatest projection of the medial
Medial Dermolipectomy of the Thigh
a a
b b
a a
a
ab
b legs, the line “ab,” and the landmark thread must be maintained through-
Fig. 4 Patient in orthostatic position. (a) The incision line, positioned
in the ICG sulcus, can lead to the pubis (a) or be externally oriented
along the sulcus (b). (b) Line in the ICG sulcus and dotted-line incision,
positioned lower if the intent is to increase the height of the labia
majora. Point “a” is the transition point between crural and gluteal
regions. Point “b” the most projected part of the medial epicondyle of
the femur. Line “ab”
epicondyle of the femur as “b.” The union of the two points
results in the line ab, located in the medial region of the thigh.
This must be drawn and maintained for the entire duration of the
surgery because it will be a line of incision. This method makes
the final scar less visible from both the front and rear views.
457
b
ab
Fig. 5 (a) Legs in a gynecological position with a trunk-femoral angle
of about 100°, slightly apart and symmetrical. (b) The position of the
out the surgery
3.1.2 Positioning on the Surgical Table
Mechanical and chemical asepsis of the involved area is car-
ried out, and a catheter is inserted and preferably maintained
until the patient is discharged.
The patient is placed on the operating table in a gyneco-
logical position, with a trunk-femoral angle of about 100°
and the legs slightly apart and symmetrical. It is necessary to
fix a landmark thread at point a, outside the line of incision,
half a centimeter toward the labia majora, leaving one of its
extremities as long as the distance ab. The position of the
legs, the line ab, and the landmark thread must be maintained
throughout surgery (Fig. 5).
458
Fig. 6 Obesity: medial liposuction must be carried out in an aggressive
manner
3.2 Dermolipectomy
In cases of obesity, dermolipectomy must be preceded by
liposuction during the same surgical procedure. In cases of
severe obesity it is preferable to perform the liposuction in a
preceding surgical period. It must be moderate, with the
exception of the medial region of the thigh, which must be
aspirated in an aggressive way (Fig. 6).
To better identify the medial surface to be aspirated with
greater intensity, once the patient is positioned with the
thighs in a vertical position, the excess tissue of the median
region must be rotated en bloc in an anteroposterior direc-
tion. The landmark thread is extended from a to b and a verti-
cal, anterior line is demarcated, which corresponds to the
projection of the thread on the skin. Following the same pro-
cess, a posteroanterior rotation is performed and another ver-
tical, posterior line traced. In this way, a triangular area is
outlined with the base facing the sulcus, which corresponds
to the area where the thickness of the subcutaneous tissue
must be reduced by liposuction, fading out toward the two
external lines that delimit the triangular area. The line ab is
located in the center (Fig. 7).
The dermolipectomy is progressive and begins with a first
phase of “lifting” with an incision in the ICG sulcus. The
procedure enables the correction of the alteration of the
medial aspect of the thigh in its upper third (Fig. 8).
When there is also widespread flaccidity and fat, to
achieve more significant reduction in volume, one proceeds
to a second phase of “tonification/circumferential reduction”,
with a vertical incision along the line ab. This will also result
in a scar on the medial region of the thigh, which usually
tends to become hypertrophic in its evolution up to the third
month. Subsequently it undergoes involution until the sixth
F. Saccomanno
month, when it becomes stable, and then fades with time.
This process should be explained to patients during the plan-
ning phase ahead of the operation (Fig. 9).
3.2.1 First Phase: Lifting
This begins with an incision in the sulcus, along the line
demarcated in patients with a labia majora of normal height.
In those with a small labia, an incision is performed on a line
parallel to the previous one, 1 cm lower in the inguinal and
crural area (see Fig. 4b). This will allow, during suturing, an
increase in height of the labia majora and/or the correction of
any distortion resulting from previous surgery. The subcuta-
neous tissue in the inguinal and gluteal regions must be
incised obliquely in a fluted beak shape externally to pre-
serve the superficial lymph nodes in the inguinal region and
reshape the contour of the buttock in the gluteal region. In
the crural region, the incision must be perpendicular to the
skin up to the fascial plane (Fig. 10).
Dissection of the skin flap at the prefascial level is per-
formed for the extension needed to stretch the excess skin of
the medial region that, due to gravity and the vertical position
of the leg, overhangs the incision line. The skin flap exceed-
ing the line of the sulcus is advanced in an apical direction
and incised vertically along ab, dividing it into two triangular
flaps. To calculate the excess skin to be removed, the thigh is
positioned more medially, and the apex of the vertical inci-
sion must touch the end of the adductor muscle fascia at point
a, where it is sutured with a provisional stitch (Fig. 11).
The two triangular flaps obtained in this way are rotated
respectively in apical and medial directions. The projection
of the landmark thread fixed at point a should be extended
without tension until the beginning of the inguinal sulcus
incision first, then the gluteal sulcus, marking on the flaps the
line of resection of excess skin in the proximal region of the
thigh. The excess is resected and the margins sutured with
provisional 3-0 silk stitches, taking care to rotate the skin of
the thigh in both anteromedial and posteromedial directions,
compensating medially the inferior flap (Fig. 12).
In excessive proximal flaccidity, diffuse cutaneous flac-
cidity, and obese thighs, an excess of medial skin is formed
that cannot be accommodated. Its correction involves an
added period of surgery with vertical incision on the line ab,
proceeding with the second phase of tonification/circumfer-
ential reduction (Fig. 13).
This type of orientation of the flaps limits the length of
the scars of the sulcus and maintains the aesthetic integrity
of the region, preventing skin displacement from the crural
region toward the anterior region, which would give an
unnatural “upward-stretching” appearance of the inner por-
tion of the thighs.
Medial Dermolipectomy of the Thigh 459

a b

c d

Fig. 7 (a) Positioning. (b) After rotating en bloc, with the skin of the direction, the landmark thread is extended again from “a” to “b” and a
median region of the thigh in an anteroposterior direction, the landmark posterior line is drawn. (d) The outlined area indicates the region that
thread is extended from “a” to “b” and an anterior vertical line is drawn. (c) should be aspirated more aggressively to reduce the thickness of subcutane-
After rotating the skin of the median region of the thigh in a posterior-anterior ous tissue in preparation for the cirumferential reduction phase

3.2.2 Second Phase: Tonification/
Circumferential Reduction
This phase of surgery must be performed before fixing the
flaps.
After the resection of the proximal skin excess, in cases
of diffuse cutaneous flaccidity and obese thighs, and after
the medial liposuction already described, skin excess in the
crural region is formed. Superficial incision along the line
ab, from a to b is performed, for a length that must be as
long as the extent of the problem to be corrected. In serious
cases, it can extend to the knee. Two subdermal flaps, ante-
rior and posterior, are then packaged. One at a time, these
must be dissected for the extension needed to permit their
rotation over the incision line ab. The anterior flap is rotated
posteriorly and the posterior one rotated in an anterior direc-
tion. The projection of the thread extending from point a to
point b defines the line of resection of the two flaps, and
positions the scars in a linear and symmetrical manner
(Fig. 14).
In flaccid thighs this results in an increase in general skin
firmness without significant reduction in volume (Fig. 15).
In obesity, where the goal is the reduction of circumfer-
ence, the thickness of the flap of the previously lipoaspirated
median region permits reduction of the perimeter with the
460 F. Saccomanno

Fig. 8 Cases A and B, proximal a

skin flaccidity, pre- and
postoperatively at 6 months. The
photo does not reflect the true
extent of skin flaccidity. One
means of assessment is to make
the patient spread the legs while
keeping the feet parallel, until the
inner thighs touch each other.
Measure the distance between
the knees in the pre- and
postoperative phases

b
Medial Dermolipectomy of the Thigh 461

Fig. 9 General obesity, lifting

a b
with circumferential reduction.
Pre- and postoperatively at 6
months in anterior view (a) and
medial view at 3 months with
symmetrical scars (b)

c d
462 F. Saccomanno

a b

Fig. 10 Oblique incision of the subcutaneous tissue in the inguinal and gluteal (a) regions, and perpendicular (b) to the fascia in the crural region

ab ab

Fig. 11 Vertical incision along “ab” of the flap in excess (a), which after dissection falls because of gravity, overhanging the incision line and
provisional suture of the apex of the incision at point “a” (b)
Medial Dermolipectomy of the Thigh
a
Fig. 12 Apical and medial rotation of the flaps, anterior and posterior transposition of the edge of the landmark thread placed at “a” (a), which
facilitates the calculation of excess proximal skin and its resection (b)
b
ab
a
Fig. 13 After resection of proximal excess skin, the skin of the thigh,
both anterior and posterior, is oriented in the medial direction (blue
arrow) and the margins sutured with provisional 3-0 silk stitches (yellow
arrows). When at the height of point “a” excess skin is formed (raised
with forceps), its correction involves vertical incision on the line “ab”
463
a
single excision of excess skin dissected at subdermal level.
Vascularization and lymph vessels are not incorporated in
the dissection. If liposuction to the medial region is not per-
formed, the flaps should be resected at full thickness to
obtain a circumferential reduction. The incision in these
cases could affect the superficial venous circulation in its
most distal part. The saphenous vein, directed toward the
knee, thus becomes more medial and superficial, with the
risk that it can be inadvertently included in the tissue to be
removed and resected. It is sufficient to ensure that it is
wrapped by a layer of subcutaneous tissue, thus keeping
intact the venous and lymphatic circulation. We now proceed
to the fixing of the flaps.
3.3 Fixing the Flap
We must pay special attention to the fixing of the flap, as this
is key to the final positioning of the scar. This step is per-
formed only after excision of the excess skin, before replac-
ing the primary stitches in the ICG sulcus. This is a
dermoperiosteum fixing, simple to perform and efficient.
Dissection of the subcutaneous tissue of the labia
majora at the prefascial level is performed, from the pubic
tubercle to the ischial ramus (Fig. 16b). The skin flap is
sutured to the periosteum from the pubic tubercle to the
ischial ramus with four equidistant stitches using 00
Vicryl thread with a semicircular cylindrical needle of
2.8 cm in length (Figs. 16 and 17).
464 F. Saccomanno

a b c

ab
ab ab ab

A B C

Fig. 14 (a) Incision on the line “ab” and dissection of excess skin. (b, c) Anterior repositioning of the posterior flap over the line “ab” and projec-
tion of the landmark thread on the flap with resection of excess transversal skin of the thigh. (d) Final symmetry of the incisions

Beginning at point A, palpating the ischium with a finger,
the needle is passed at a 90° angle, toward the bone, and is
anchored to the periosteum with no risk to other structures.
Subsequently, the needle is passed through nearly the
entire thickness of the thigh flap, including adipose tissue,
fascia superficialis, and deep dermis. At the level of the flap,
the needle must “pinch” the dermis at a distance of approxi-
mately 0.5–1 cm inside the incision line. Maintaining the
gynecological position, each leg, in turn, must be moved
medially and the stitch with the knot toward the outside must
be tightened, taking care not to leave subcutaneous tissue
within the knot. With the same procedure, we then fix the
flap to the pubic tubercle and subsequently to the two central
equidistant points on the ischial ramus (Fig. 17).
This type of dermoperiosteal fixation gives stability to the
position of scars and maintains the original height of the labia
majora. It also allows an increase in the small labia and a degree
of correction in those that are distorted (Fig. 18; see also Fig. 4).
In both the lifting and circumferential reduction phases,
the extension of the dissection must correspond, as far as
Medial Dermolipectomy of the Thigh 465

a b c

Fig. 15 (a) General skin flaccidity. Lifting and circumferential tonification. (b) Pre- and postoperative views at 3 months with hypertrophy of the
scar, and (c) at 3 years, with acceptable scar and tone preserved

Fig. 16 (a) Skin projection

a b
of the fixing stitches. (b) Fixing
stitches from the pubic tubercle
to the ischial ramus after pubic
dissection at a suprafascial
level

possible, to the excess skin resected. In so doing, the dead
spaces are minimal so that drainage is not necessary.
In cases where the correction includes the medial region
of the knee, the incision must be extended in a posterior
direction, in the popliteal crease.
The suture is performed in layers with good support of the
deep dermis. The sulcus skin must be sutured with eversion
of the margins using interrupted stitches. The vertical suture
should be continuous, intradermal, and absorbable. The
author uses 4-0 monofilament.
The dressings are occlusive. In vertical dressings, the
margins of the flaps are maintained by hypoallergenic paper
tape. These are non-circumferential, to limit tension, but at
the same time do not hinder normal swelling.
466 F. Saccomanno

b c

Fig. 17 (a) Pubic tubercle and ischiopubic ramus. (b) Passage of the needle through the periosteum. (c) Anchorage of the flap, including adipose
tissue, fascia superficialis, and deep dermis

When dermolipectomy is combined with liposuction, 3.4 Postoperative Care

after medicating, the legs are dressed in the operating room
with 140-denier stretch pantyhose of one size greater than
that of the patient.
Antibiotic and fibrinolytic anti-inflammatory therapy is
prescribed. In obesity and diffuse flaccidity, for which surgi-
cal aggression is greater and surgical time longer, DVT pro-
phylaxis is also indicated.
Early ambulation. Patients are discharged after one day of
hospitalization. The bladder catheter and dressings of the
sulcus must be removed the day after surgery and the wounds
left uncovered, allowing the possibility to be washed and
dried with swabs. The stitches in the sulcus are removed by
the 7th postoperative day, otherwise they can lead to skin
Medial Dermolipectomy of the Thigh
a b
Fig. 18 The skin of the radix of the thigh above the incision line when repositioned at the top, by fixing the flap, becomes a wall of the labia
majora, increasing the height
maceration. Vertical dressings must be removed on the 5th
postoperative day. To reduce the tendency to hypertrophy of
the vertical suture, the application of hypoallergenic paper
tapes is advisable for a month or more, with daily changes.
Tight undergarments that rub on the scars of the sulcus are
not recommended, but rather some type of loose underwear
for a period as long as possible, even up to 3 months.
In the case of liposuction, compression stockings will be
worn for about a month, day and night, taking care not to
push down the flaps when undressing. Patients should be
advised to refrain from flexing or spreading their legs apart
for a long period.
It is advisable for the patient to undergo lymphatic drain-
age after the 7th postoperative day in cases with vertical
scars and in all cases where liposuction has been involved.
4 Complications
General complications reported in the literature, such as pul-
monary embolism or massive infection, are very rare.
Specific complications are more frequent and increase when
associated with liposuction and other body-contouring oper-
ations. Following the previously described planning, the spe-
cific complications of the immediate postoperative period
such as local infection, hematoma, and skin necrosis are rare.
The suture of the crural region, especially at the level of the
fixing points, requires particular attention in the postopera-
tive period because of moisture that tends to soak the wound,
causing dehiscence. This can be resolved with daily medica-
tion. The most severe complication is downward migration
of the scar, leading to the distortion of the labia majora with
467
serious gynecological repercussions, including irritation and
inflammation, repeatedly in the event of a gaping vagina.
These complications, although not evident in the immediate
postoperative period, may appear later because of gravity, if
the flaps were not properly anchored. In this type of interven-
tion, the positioning of the incision line of the sulcus, the
orientation and fixing of skin flaps, and the patient’s own
postoperative care are of fundamental importance. The four
phases in the planning described earlier, if performed care-
fully, reduce the incidence of scar migration and prevent
complications such as the flattening of the ICG sulcus,
stretching of the labia majora, distortion of the buttock, and
asymmetry of both form and volume of the legs. In addition,
this technique can be used for the correction of secondary
deformities.
5 Informed Consent
Protocol of the informed consent of the Italian Society of
Plastic, Reconstructive and Aesthetic Surgery (SICPRE).
The purpose of the following consent form is to provide
the patient, in addition to the preoperative information given
by the surgeon, clarifications concerning the characteristics
and risks associated with thigh-lift surgery. Please be sure to
read the following carefully, discuss with your surgeon the
explanation of each item which is not clear, and then sign
this document as confirmation that you have understood the
information received.
Redundancy or laxity of the inner thighs can be corrected
by surgery. This operation, called thigh lift, is aimed at
removing the excess skin of the region of the inner thigh. It
468
is necessary to be aware that, in any case, it is not possible to
restore the tone and the compactness that tissues usually
have at youth. Large scars from the inguinal sulcus (groin) to
the gluteal fold of the buttock remain. Sometimes, vertical
scars can remain on the inside of the thighs; in severe cases,
these can lead down to the knees. The stitches of the sulcus
may, however, migrate below the sulcus due to the force of
gravity, thus becoming more visible. Vertical scars, when
present, may tend to hypertrophy. The operation is necessar-
ily performed under general anesthesia. Overnight stays
(usually 1), frequency of medication, and the removal of
stitches depend on the individual case. The result is generally
satisfactory from the earliest stages, although scar readjust-
ment may be required later.
5.1 Before Thigh-Lift Operation
• Inform the surgeon of any possible treatment with drugs
(especially steroids, contraceptives, antihypertensives,
cardiac, anticoagulants, hypoglycemics, antibiotics, tran-
quilizers, sleeping pills, stimulants, etc.).
• Stop taking medicines containing acetylsalicylic acid
(e.g., Alka Seltzer, Ascriptin, Aspirin, Bufferin, Cemerit,
Vivin C, etc.) or other NSAIDs.
• If possible, indicate the periods of the menstrual cycle.
• Eliminate or reduce smoking at least 1 week prior to
surgery.
• Immediately report the onset of a cold, sore throat, cough,
skin diseases.
• Arrange for the presence of a companion for the immedi-
ate postoperative period. Extra assistance can be useful,
though not essential.
• Purchase a140-denier-strength elastic stocking in the case
of combination with liposuction.
5.2 On the Eve of Thigh-Lift Operation
• Do not consume food or drink from midnight.
• Clean thoroughly in bath or shower, remove all nail polish
from hands and feet; shave the pubic area.
5.3 The Day of Thigh-Lift Operation
• Maintain strict fasting and wear a nightgown with very
comfortable sleeves and open at the front.
F. Saccomanno
5.4 After Surgery of Thigh Lift
• Have someone accompany you home by car.
• Do not drive for at least 2 weeks.
• Do not resume sexual activity before 3 weeks have passed.
• Do not wear tight undergarments that rub against the scars
of the groin. Instead, choose loose undergarments such as
boxers for the longest period possible, even up to 3 months.
• For at least 3 weeks wear elastic stockings if prescribed,
even during the night.
• Do not play sports or exercise for 1 month. For 3 months,
avoid fully spreading or stretching the legs.
• You may take a shower after the first medication that usu-
ally takes place on the 5th postoperative day.
• For at least 1 month, avoid direct exposure to sun or heat
(e.g., Sauna, UVA lamps)
• Do not hesitate to contact your surgeon if you have any
questions or doubts about your postoperative recovery or
treatment.
5.5 Informed Consent to Thigh-Lift
Operation
................................ The ................ .....
I, the undersigned
Name ................................... ......................................
Surname ...................... ................................
DECLARE that I have read the informed consent protocol
attached to this form.
In addition, the operation was illustrated in detail by the
surgeon and I understand its goals and limits.
In particular, I know that:
• Residual scars will result from the operation. In some cases,
the scars can migrate below the inguinal sulcus (groin), thus
becoming visible outside the panty line. The vertical scars,
if any, may be hypertrophic by the 3rd month and stabilize
around the 6th month. The color will normalize over time.
In the post-operative period, tension will be felt especially
during walking. This will diminish within a few days.
• It is possible that edema and ecchymosis occur, which
have a tendency to migrate downward. These usually dis-
appear within a month. In rare cases, edema may persist
in cases of more severe corrections or when associated
with general liposuction.
• Sensitivity of the inner thigh can remain altered for a vari-
able period and can be permanent.
• The operation of thigh lift, like all surgical procedures, is
subject to complications such as hematoma, seroma and
infection.
Medial Dermolipectomy of the Thigh
I AUTHORIZE
Dr . ……………………………………………………….
And his/her employees to perform on me the surgical pro-
cedure ………………………………… .
I know that I will have to undergo an
aesthesia.……………………………………..
I AUTHORIZE
Dr………………………………………………………
and his colleagues to change operative and postoperative
techniques and strategy according to their expertise and
necessity.
I agree to follow the medical and physical therapy that
will be required in the postoperative period, and have been
informed of the adverse consequences to the success of my
surgery should I fail to do so.
Because surgery is not an exact science, the precise result
cannot be planned in advance, as the healing process depends
not only on the surgical techniques employed, but even more
so on the body’s responses.
Possible complications, such as hematomas, seromas, or
infection, can be treated; to this end, I agree to undergo the
necessary treatment, including surgical intervention if
required.
I agree to be photographed before, during, and after sur-
gery, with the knowledge that the surgeon agrees to use such
images exclusively for the purpose of clinical documentation
and with an absolute guarantee of anonymity.
.................................................. ..................
Signature of patient
.................................................. .................
Signature of the guardian in case of minor
.................................................. ..................
Signature of the surgeon
Bibliography
1. Lewis JR Jr (1957) The thigh lift. J Int Coll Surg 27:330–334
2. Pitanguy I (1972) Dermolipectomies crurales. Ann Chir Plast
17:40–46
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3. Ducourtioux JL (1972) Technique et indications des dermolipecto-
mies crurales. Ann Chir Plast 17:204–211
4. Vilain R, Dardour JC (1986) Aesthetic surgery of the medial thigh.
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5. Hoffman S, Simon B (1975) Experiences with Pitanguy method of
correction of trochanteric lipodystrophy. Plast Reconstr Surg
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6. Baroudi R, Carvalho GSC (1981) Lifting de la cara superointerna
del muscolo: estudio analitico a corto y largo plazo. Cir Plast Ibero-
Latinoam 7:275
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1980
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patients. Ann Int Symp Adv Plast Surg S. Paulo, 28–30 March
1990, p 441
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(1996) Superficial liposuction. Aesthetic Plast Surg 20:111–122
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Aesthetic Plast Surg 28(1):20–23
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degli arti inferiori: schema di trattamento chirurgico. In: Proceedings
of the 38° Meeting of the Italian Society of Reconstructive and
Aesthetic Plastic Surgery, Messina, 20–23 Sept 1989
 Gluteoplasty
Constantino Mendieta
To implant or not to implant? That is the gluteal question.
1 Introduction
The ability to augment the buttock has existed since 1969
when Bartles et al. [1] first described the reconstruction of a
unilateral gluteal agenesis by placing a Cronin breast sili-
cone implant above the gluteus muscle. Over subsequent
years, other authors described similar reconstructive proce-
dures for the treatment of asymmetry and gluteal depressions
[1]. However, it was not until 1973 that the first successful
augmentation for cosmetic purposes was published by Cocke
and Ricketson [2] from Nashville, TN.
Despite its US origin, gluteal augmentation never devel-
oped a following in the United States, and it was the Latin
American plastic surgeons that popularized and refined the
technique as a cosmetic procedure. In 1981, Gonzalez-Ulloa
developed an interest in the area and placed gluteal implants
above the muscle through bilateral infragluteal crease inci-
sions (bottom of the buttock). He was among the first to
develop an implant line that was specifically designed for the
buttock, marking the birth of the almond-shaped gluteal
implants [3]. Up until then, breast implant had been used for
buttock augmentation. Gonzalez-Ulloa published his 10-year
experience in 1991 describing his technique but also
described a new incision approach – the bilateral interglu-
teal incisions (moving the incision from the bottom of the
buttock to the inside of the midline gluteal crease).
Up until this point, only subcutaneous buttock augmenta-
tion had been described, but in 1984, Dr. Robles [4] pub-
lished a landmark article in which he described the
intramuscular technique through a central single intergluteal
incision. He also introduced his own line of round gluteal
implants making the choices for gluteal implants more
intriguing.
C. Mendieta, MD, FACS
Private Practice, Miami, FL, USA
e-mail: cmendi@aol.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_33
Unfortunately, gluteal augmentation as a procedure lay
dormant for the next 10 years with very little advancements
or publications until 1994 when Dr. Rafael Vergara pub-
lished his experience with an anatomic implant that he devel-
oped for the intramuscular plane. Then in 2000, Dr. Albe de
la Pena published his work describing a new surgical plane
and described the new implant he designed specifically for
the subfascial plane [5].
Gluteal augmentation was now developing wings since
we had different incision locations, different implants to
choose from, and now different planes of placement.
However, despite its 30-year history, the procedure remained
in its infancy and had not flourished like other procedures
such as breast augmentation, facelifts, or body contouring
where extensive articles had been written. Physician’s inter-
est remained low since they still remained unfamiliar with
the anatomy, they perceived a high complication rate, and
there was lack of publications.
This would all change in the early 2000s as the public inter-
est began to peak with the appearance of Jennifer Lopez,
Serene Williams, and other personalities that accentuated and
flaunted their god-given curves. As patients began to inquire
what could be done, physician interest began to increase, but a
vast majority still remained hesitant since the operative tech-
niques were not well understood; patient selection remained a
mystery, and no evaluation system existed to universalize our
approach. Consequently, avoidance of this area was still the
mainstay.
In 2003, I published my experience with intramuscular
implants in which patients described a tremendously high
satisfaction rate, but clinically, there was a 30 % wound
dehiscence rate [6]. Up to this point, no article had addressed
complications, complication rates, patient selection, implant
selection, plane selection, etc. My focus turned from simply
trying to master the technique to trying to decrease the com-
plication rates and make the procedure safer and more
appealing to surgeons.
471
472
Fig. 1 A 30-year-old female 9 months post-op following liposuction of the abdomen, flank, sacrum, and fat transfer to the buttock placing 800 cc
on each side
The procedure has evolved tremendously over the last 8
years, and this chapter will focus on how to augment the but-
tock safely with implants or with fat and provide guidelines
for patient selection, implant selection, incision location, and
surgical plane selection and in identifying patients that are at
a greater risk for developing complications.
Mastery of this procedure requires both knowledge of rel-
evant clinical anatomy and familiarity with the properties of
the various implants available to the surgeon.
2 Who Is a Candidate?
Gluteal augmentation is not just about making the buttock
bigger, but rather accentuating, contouring, and reshaping.
The focus becomes volume redistribution, shifting volume
from an unattractive zone to a more desirable curvaceous
position. With this perspective, even the full-figured woman
becomes a candidate since on closer examination the large
buttock has maldistributed adiposity with deficient volume
in pertinent aesthetic zones (Fig. 1).
The question is no longer “who is a candidate?” but rather,
“what reshaping method is best for our particular patient?”
Liposuction is for sculpting, while fat transfers and implants
C. Mendieta
are used for volume expansion. Which augmentation method
is chosen becomes our first challenge.
3 Implants Versus Fat: What to Use?
Our initial complication rates for implant augmentation were
published in 2003 in which we identified a wound dehis-
cence rate of 30 % and implant exposure and infection rate of
2–3 % [6]. These rates did not take into consideration the
different body frames and body or implant sizes; rather, they
were bundled under the heading of “gluteal augmentation.”
During this 2003 published series, by far the biggest patient
complaint was the augmentation not being big enough
(Fig. 2). Patients demanded large volumes.
In trying to fulfill patient’s expectations, larger implants
were used; however, complication rates soared with wound
dehiscence rates increasing to 40–50 % and implant expo-
sure rates rising as high as 30 %. This was unacceptable
making it very clear that not everyone was a candidate for
implant gluteal augmentation. But then, who was?
Through a retrospective review of 150 intramuscular
cases, two factors were noted; most of the dehiscence and
implant exposures occurred in large patients or patients
Gluteoplasty
Fig. 2 Implant augmentation showing minimal difference. She had intramuscular medium round implants placed 2 years ago
seeking large augmentations. While at face value this obser-
vation seems obvious and simplistic, you must remember
that for gluteal augmentation, no guidelines or parameters
existed; therefore, the question became more complex: what
patient is too large? What implant is too big? What is the
threshold? In order to help answer these questions, patients
were evaluated based on body frame size and the degree of
muscle tension at closure. To assess body size, patients were
divided into four groups: those with a small frame, medium
frame, large frame, and extra large frame. Muscle tension
was categorized as either having tension or no tension at clo-
sure. Implant exposure and wound dehiscence were com-
pared. The results were as follows (Figs. 3, 4, 5, and 6).
4 What Does This Mean?
In my practice, when approaching patients for gluteal aug-
mentation, fat is the preference; it is an autologous tissue.
Patients have an easier recovery and fat transfers have fewer
complications than implants. Besides, any time, you can
avoid a foreign body you don’t have to contend with implant
473
issues that may arise several years down the road (whatever
they may be). The goal therefore is to identify the patient
with enough donor fat to make a significant difference in the
augmentation. Dividing patients into these different body
frames has identified different complication rates and goes a
long way in helping develop an algorithm to select the best
augmentation method.
How do we do this?
5 How Do We Distinguish the Frames
As surgeons, we would like some sort of scientific method to
help guide and standardize these four body frames. While
the approach used was very subjective, in an attempt to
cement a standard tool, several evaluation methods were
examined: percent body fat, body mass index, dress size (for
females obviously), and/or presacral fat measurements.
Since most surgeons don’t walk around with calipers to mea-
sure body fat, this test becomes cumbersome. Body mass
index is a good guide but is not reliable in very athletic indi-
viduals; it also loses some of its interpretative value if the
474
Fig. 3 Small frame (BMI 19)
patient is taller than 5’6” (personal observation). Female
dress sizes are also helpful; however, they were misguiding
in individuals taller than 5’6” (personal observation). Despite
these limitations, we can attempt to make some generaliza-
tions based on body mass index and female dress sizes. The
small-framed patient usually has a BMI of 20 or less (dress
size 0–2), the medium framed has a BMI of 21–27 (dress
size 3–9), the large framed has a BMI of 28–31 (dress size
10–14), and finally, the extra large framed usually has a BMI
of 32 or greater (dress size greater than 15). If the BMI is 20
or less, the patient will usually not have enough fat for aug-
mentation, and implants are the volume enhancer of choice.
Patients with a BMI of 28 or greater usually have abundant
lipodystrophy and are best augmented with fat (exceptions
may exist).
What has been most helpful in patient selection has been
“presacral fat measurements”; anyone with 6–7 cm presacral
thickness will usually have the body type that has sufficient
fat for transfers. These patients tend to have a very square to
C. Mendieta
Fig. 4 Medium frame (BMI 20)
V-shaped gluteal appearance with flank/upper buttock lipo-
dystrophy that exceeds the gluteal margin. There is an excess
layer of fat over the sacrum which makes these patients sus-
ceptible to wound dehiscence if implants are used (Fig. 7).
In summary, there is no full proof system that will indi-
vidualize each patient given all the fat variables discussed. In
our series, the patients were categorized by visually compar-
ing them to Fig. 6. Since a picture is worth a thousand words,
this is perhaps the best system to help categorize the different
body frames.
However, we should start considering fat transfer as the
preferred choice for augmentation in patients that have a
BMI of 24 or greater, a dress size above 8, or a 5–6 cm pre-
sacral fat thickness. However, physicians’ judgment and
experience coupled with photographic categorized body
frames in Fig. 8 will be the best tool.
Gluteoplasty
Fig. 5 Large frame
5.1 If Fat Transfers
Evaluation of patient for fat transfer requires several factors
to be considered.
Depending on patient size and desired volume enhance-
ment, gluteal augmentation with fat requires 300–800 cc of
good transferable fat per side. Obviously, the larger the
patient, the larger the required volume; in the small-framed
individual, 300–450 cc will be needed, in the medium framed
450–650 cc, in the large framed 550–750 cc, and in the extra
large 650–850 cc, occasionally 1,000 cc, per side. We must
remember that not all of the aspirated fat is viable and each
patient has different fat characteristics; some fat is easily
destroyed on suctioning, while others have very dense fibrous
fat that may be difficult to transfer through the cannula.
Complicating the issue further, some patients have a bloodier
aspirate which further limits our ability to suction. These
variables cannot be predicted prior to surgery and makes the
quantity of “transferrable fat” unpredictable. As a general
475
Fig. 6 Extra large frame
rule, only ½–3/4 of the “total supernatant aspirate” is good
for transfer, which means we will need 1,000–4,000 cc of
“total supernatant fat” to render 600–2,000 cc of good “trans-
ferable fat.” These volumes have also been substantiated by
others [7]. Clearly, some patients will not have that volume
to spare and the small-framed individual is exactly that
patient; they are best augmented with implants [8]. The
large- and extra large-framed individuals are ideal for fat
transfers given the excess fat. The challenge lies in the
medium-framed individuals since they may or may not have
an adequate amount. It is in these patients that one’s experi-
ence and comfort level will need to take precedent in the
decision-making process. The medium-framed individual is
given three procedural choices for augmentation: fat,
implants, or a combination of both.
1. If gluteal augmentation with fat transfers is chosen, the
patient understands the final results are influenced by two
unpredictable variables (Fig. 9):
476 C. Mendieta

Fig. 7 V-shaped gluteal appearance

Fig. 8 Surgical indications related to frame

Gluteoplasty
Fig. 9 A 22-year-old female patient had liposuction of flank, back, upper buttock, sacrum, and slight abdomen with 720 cc of fat transfers to each
buttock. She is 2 years postoperative
• The amount of available fat for transfer
• The uncertainty of the fat survival
• It will take 3–6 postoperative months to determine the
amount of fat survival. In our series, there was a
60–75 % survival rate, but it could easily be much less.
If after 6 months the patient desires a larger augmenta-
tion, implants can be used. On many occasions, the
patient is unwilling to take the risk of having two
procedures.
2. If the patient is not willing to take the chance, implant
augmentation is our first choice (Fig. 10).
3. If the patient is looking for a large augmentation and our
size of implant is limited, we can add fat at the same time
or at a later date to further enhance volume (Fig. 11).
5.2 Implant Selection
Implants have a variety of textures, shapes, and sizes. The
implant content can be a solid silicone elastomer or silicone
cohesive gel. The gel implants are used in the international
477
circles, whereas we are limited to the elastomer implants.
The most common shapes are round, anatomic, and oval
(Fig. 12).
Implant selection will depend greatly on which plane is
chosen to augment the buttock: subfascial or intramuscular.
Each plane has different tissue dynamics and responds very
differently to the augmentation.
5.3 Augmenting the Subfascial Plane
In this plane, tissues are more pliable, but they are thinner; if
implants are improperly selected, they may become palpable
with visible edges and over time may lead to gluteal ptosis
(Fig. 13).
This is particularly true if the round or oval implants are
used. The best subfascial implant is the one designed by Dr.
de la Pena since his implant is specifically designed for this
plane, and he has spent a tremendous amount of time
designing, engineering, and developing this particular tech-
nique [5]. This plane does offer a quicker recovery with
478 C. Mendieta

Fig. 10 A 29-year-old female 8

months after large anatomic
intramuscular gluteal
augmentation
Gluteoplasty 479

Fig. 11 A 31-year-old female

who had round large
intramuscular implants placed 1
year later she had fat transfers
placing 300 cc on each side. She
is 6 months postoperative

much less postoperative pain. Since our international col-
leagues can use silicone gel implants, palpability is not a
big issue. If the patient has good tissue coverage with
proper patient selection and the use of gel implants, you
can achieve nice and natural augmentations. In the
subfascial plane, the only decision that remains is size
selection and implant texture. Dr. de la Pena has developed
some very nice preoperative external templates that guide
you in size selection. I would refer you to his well-written
articles [5, 9].
480
Fig. 12 Implant shapes
Anatomic
In the United States, however, we are limited to the elasto-
mer implants; these implants are firmer, more palpable, and
less giving; therefore, obtaining tissue coverage is a priority.
Placing the elastomer implants in the muscular plane will
help camouflage the firmness of the implant giving a more
natural feel and appearance. Given our implant restrictions,
this plane becomes more appealing. The intramuscular
implant selection process will involve deciding on implant
shape, size, and texture. The smooth implant is preferred
since there seems to be a lower incidence of seroma
formation.
Implant shape for the intramuscular plane requires eval-
uating two aspects: the muscle height-to-width relationship
in the PA view and the volume of distribution in the lateral
view.
Implant size selection is a decision made intraoperatively
with the aid of a sizer.
5.4 Muscle Height-to-Width Ratio
To find this relationship, identify the superior and inferior
points of the gluteus muscle as well as the most medial and
lateral points. At a glance, you will notice a height-to-width
relationship which will fall into one of three ratios: 1 to 1
(short muscle), 2 to1 (tall muscle), or intermediate 1–2 to 1
(Fig. 14); ideal buttock is intermediate but leans more toward
a 2 to 1 relationship (see Fig. 14a).
The short muscle is best augmented with round implants
since they have similar ratios (1 to 1): the tall muscle (2–1) is
best augmented with an anatomic implant [10]. The interme-
C. Mendieta
Oval Round
diate muscle has the most flexibility since any of the three
types could be used: < round, anatomic, or oval. However, in
these cases, it is best to use the lateral view to make our final
decision.
5.5 On Lateral View
The gluteus is divided into three zones: upper, central, and
lower (Fig. 15).
The lateral view will evaluate where most of the bulk of
the gluteal volume is located. In the aesthetic buttock, most
of the volume is central and has equal distribution in the
upper and lower gluteal zones, giving a nice C-shaped curve
(Fig. 14). It has been suggested that the peak of the central
mound should be at the level of the pubic bone. In our evalu-
ation, we need to deem where most of the volume is located:
lower, central (mid-buttock), or upper buttock (Fig. 16).
If the bulk of the gluteal volume is in the lower buttock,
a round implant will look best since the round implant adds
most of its projection in the upper and central zones, equal-
izing the volumes throughout the buttock. If the bulk is cen-
tral, the buttock is already well balanced so any implant
will look good; I have a preference toward the oval or round
implants. If the bulk is in the upper buttock, an anatomic
implant will have the best result since the anatomic adds
most of its volume inferiorly. If in these cases a round
implant is used, it will accentuate the already full upper
buttock which in turn will accentuate the lower gluteal defi-
ciency making the buttock look very disproportionate
(Fig. 17).
Gluteoplasty
Fig. 13 Patient with subfascial round implants placed too low overtime
had descent
6 Implant Size Selection
6.1 Decreasing Implant Exposure
In attempts to decrease implant exposure, I spoke with my
mentor in gluteoplasty Dr. Jorge Hidalgo and revisited the
operation. Once the implant is in place, the muscle edges
should almost be opposing (kissing edges); in this way, very
little tension is placed on muscle closure. Some patients have
a very lax/loose muscle and can easily accommodate large
implants, while others have very tight fibrous attachments
with dense muscle fibers that can barely tolerate medium-sized
implants. Interestingly enough, the degree of athletic built or
activity has nothing to do with the degree of muscle tension.
481
I have seen body builders with lax muscles and sedentary
patients with very dense tight fibers. There seems to be a
genetic and cultural predisposition with Afro-Americans
having the tightest attachments.
Since each patient’s anatomy is unpredictably different
and implant exposure rates rise as tension increases, implant
size cannot be guaranteed or determined prior to surgery.
Sizers are used intraoperatively to identify the largest implant
the body will accommodate without creating excessive mus-
cle tension at closure. If the patient desires a larger augmen-
tation, in 3–6 months, we can either place larger implants
(the muscle has been stretched) or we can perform fat trans-
fers. Fat transfers have also been performed at the same time
as the implant augmentation.
6.2 Decreasing Wound Dehiscence:
For Placement in Any Anatomic Plane
In 1969, Dr. Crocket for reconstructive purposes used a uni-
lateral infragluteal incision. Dr. Gonzales Ulloa [3] used this
approach for his subcutaneous technique; given the visibility
of these scars, they were never in favor. Dr. Jose Robles from
Argentina [4] placed the implants in the submuscular posi-
tion through a hidden single intergluteal incision. This
became the incision of choice given its inconspicuous nature.
The technique I have used was taught to me by my mentor in
gluteoplasty, Dr. Jorge Hidalgo, which is the intramuscular
placement through the single midsacral intergluteal
incision.
Gluteal augmentation with implants has been a very hum-
bling procedure since complication rates have remained high
despite all sorts of attempts to decrease wound dehiscence
and implant exposure: fibrin glue, platelet gels, quilting
sutures, drains, variations of the central intergluteal incision,
scalpel dissection versus cautery dissection, immobilization,
a variety of postoperative care techniques including less
office visits (to decrease wound irritation), antibiotic
changes, variety of garments, etc. No matter how our preop-
erative, intraoperative, and postoperative care was manipu-
lated, no improvement was seen. Other published work did
not share my high wound dehiscence rates or issues (Table 1).
However, it became clear that the single midsacral incision
was not the best approach in our series. In searching for
alternatives, Dr. Abel de la Pena proposed a modification of
the central midline incision by creating an elliptical 8 cm
long central de-epithelialized flap.
This maintained the well-hidden single intergluteal inci-
sion but added an underlying well-vascularized dermal flap.
During my early attempts, this flap appeared promising;
however, after reviewing 14 cases, there were five
482
a b
Fig. 14 (a) Short one to one. (b) Intermediate 1–2 to 1. (c) Tall 2–1
Upper buttock zone
Central buttock zone
Lower buttock zone
Fig. 15 Buttock zones
dehiscences. It became evident that in my hands, this varia-
tion did not address my wound issues. Again, others did not
describe this great dehiscence. Perhaps one reason is that
international plastic surgeons can use silicone gel implants,
which are extremely soft and tremendously easy to introduce
causing less tissue trauma. Unfortunately, in the United
States, we are limited to the elastomer implants (Table 1).
C. Mendieta
c
Wound dehiscence therefore became a personal challenge
and battle.
7 Incision Evolution
During the search for other options, the bilateral intergluteal
incision was used. The incisions avoid the sacrum which is a
watershed area with poor circulation but still remain hidden
in the intergluteal fold.
These incisions are designed as follows: intraoperatively
with the patient in the prone position, the tip of the coccyx is
identified and marked; the intergluteal crease is drawn from
the tip of the coccyx 8 cm cephalad, staying exactly in the
sacral midline (this line will be used as our reference line).
The future incisions are marked one centimeter from this ref-
erence midline so that both incisions are 2 cm apart in the
inferior and middle portions. As the incision reaches the
upper buttock, it follows the gluteal curvature (this occurs at
about the 6 cm mark from the coccyx). This design gives two
8 cm incisions that parallel the midline from the tip of the
coccyx extending cephalad following the upper gluteal cur-
vature. The incisions at its inferior and middle portion have a
2 cm separation, in its upper portion 4–5 cm (Fig. 18). If
these distances are not respected, central skin necrosis may
occur.
The eventual scars remain hidden in the gluteal cleft;
while the upper incisions may be visible, they are hidden in
bikinis. My first case placed the incisions 0.5 cm from the
cleft; in other words, there was only a one centimeter dis-
tance between the incisions. This bridge was too narrow and
Gluteoplasty 483

a b c

Fig. 16 (a) Lower buttock. (b) Central buttock. (c) Upper buttock

Fig. 17 Patient with bulk in upper buttock, round implant used which Fig. 18 Marking for bilateral intergluteal incision
accentuates lower gluteal deficiency
484
central wound necrosis with dehiscence occurred. With our
new design, 18 cases have been performed, and to date, only
one dehiscence/implant exposure has been seen. This was in
a large-framed individual that refused fat transfers.
8 Preoperative Preparation
8.1 Fat Grafting
8.1.1 Sequencing and Patient Positioning
for Initial Fat Injections
If I am combining fat grafting with implant augmentation, I
will first harvest the fat the same as if I were performing
gluteal augmentation with fat grafting. The fat is harvested
and transferred to the areas that need it. The transition zones
a–d and I equalize the volumes in the buttock quadrants 1–4
(Fig. 19).
Fig. 19 Fat injected a superficially as possible and away from the
supra-fascial dissection zone. My goal in the intramuscular implant
pocket dissection is to have at least a 3 cm coverage over the implant
C. Mendieta
To insert the implant, I need to expose enough gluteal fascia
to facilitate implant placement (Fig. 20). This distance is usually
a 3–5 cm semicircular line that is centered at the incision. I there-
fore know that it is safe to inject outside of this dissection line.
The depth however is more difficult to assess because there
is limited visibility. The goal is to place the fat in the first 1 cm
of muscle depth because the implant pocket is created at 3 cm.
Therefore, the muscle injection is as superficial as possible. This
determination is done by feel since it is difficult to accurately
determine exactly what level I am at. I am attempting to avoid
releasing all the recently injected fat when I create my gluteal
implant pocket. Often, the muscle injections are done after I
have already introduced the implant and it is in place. Therefore,
some fat is preserved in syringes on the back table to permit
final shape and or volume adjustments after the implant is in
place. Once I have completed the frame and muscle reshaping,
I turn my attention to the gluteal augmentation. This is a totally
new procedure. All gowns and gloves are removed and the
patient prepared for the buttock augmentation.
8.2 Gluteal Augmentation
8.2.1 Patient Preparation
Ted hose and pneumatic stockings are in place and function-
ing prior to anesthesia. Preoperative medications include
Decadron 10 mg IV, Cleocin 600 mg, and Zofran 8 mg odt
for postoperative nausea. If I am not combining fat augmen-
tation with fat grafting, the procedure only takes approxi-
mately 1 h; therefore, no Foley catheter is inserted. However,
if liposuction and fat grafting are to be performed, then the
catheter is inserted prior to the liposuction.
8.2.2 Anesthesia and Patient Positioning
The procedure can be performed under general anesthesia,
spinal anesthesia, or IV sedation. The majority of procedures
I perform are done under general anesthesia.
Fig. 20 Exposure of the gluteal fascia to facilitate implant placement
Gluteoplasty 485

If the procedure is being combined with fat grafting, then
the patient was originally prepped circumferentially while in
the standing position. A sterile draw sheet is placed in the
small portion of the back to help in turning the patient during
the various stages of positioning (Figs. 21, 22, and 23).
Once the airway is secured, anesthesia infiltrated, and control
of the airway established, the staff assists with arm positioning,
and with the aid of a draw sheet, the patient is rotated to the
prone position. Once the patient is in the prone position, one
assistant will lift the pelvic girdle while the other inserts a pillow
under the pelvic bones to jackknife and hoist the pelvis to facili-
tate muscle visualization and dissection. The patient’s elbows
are flexed with arms out to the sides at less than an 80° angle and
all pressure points are padded. If the patient is female, a breast
roll is placed. The pneumatic stocking compressions are
rechecked as is the Foley catheter if liposuction was performed.

Fig. 21 If no anterior liposuction

is to be done the patient still needs
to go from the supine to the prone
position and I therefore still
suggest placing a draw sheet
under the patient prior to
induction

Fig. 22 Patient placement in

prone position
486
Fig. 23 Drape placement
Fig. 24 Marking of the sacral midline
Once satisfied with positioning, the buttock and back are
prepped and draped. If this is a combination procedure with
fat grafting and implant augmentation, then a completely
new sterile setup is used. The gluteal area is prepped from
the knees to the upper back and as far laterally as possible.
Draping should leave the entire gluteal zone and lower back
exposed; a Betadine-soaked gauze is placed over the anus
and secured with 2-0 silk so as to avoid contamination. A
sterile towel is placed over the gauze to cover the anus and
the inner gluteal zone. This towel is secured to the skin with
2-0 silk so as not to allow any space between the towel and
skin. All gloves and gowns are changed.
8.2.3 Incision Design/Markings
I use bilateral paramedian incisions. These incisions are
designed as follows.
The first step is to mark the sacral midline (Fig. 24). With
the patient in the prone position, the tip of the coccyx is pal-
pated and marked. Staying exactly in the sacral midline, I
draw the central from the tip of the coccyx 7–8 cm in the
C. Mendieta
cephalad direction along the natural midsacral crease. This
midline is now used as a reference line to help identify and
mark the incisions.
From this midline, three points are identified and con-
nected to create the incision line:
1. The most inferior aspect of the incision is identified, the
coccyx is palpated, and the first mark is made 1 cm below
and 1 cm lateral to the midline.
2. The mid-mark of incision is identified by traveling 4 cm
cephalad from this most inferior lateral point. At this 4 cm
level, a one centimeter point is marked lateral from the
previously drawn midline. Two points have now been
identified, both of which are 1 cm lateral to the midline.
3. The superior aspect of incision is identified; this portion
of the incision will follow the natural upper gluteal con-
tour. By mobilizing the buttock from a lateral to a medial
direction, this creates medial fullness, and the natural
swooping curvilinear gluteal curvature is seen. Therefore,
the third and final point is at the 7–8 cm level from the
inferior portion of the incision at the point where the glu-
teal curvature is seen. This preserves the incision follow-
ing the natural gluteal curve line.
All three points are then connected to produce a 7–8 cm
semi-curvilinear line that is 1 cm away from the midline in
the inferior middle aspect and 1–2 cm apart in the upper glu-
teal aspect. This design produces two 7–8 cm incisions that
parallel the midline from the tip of the coccyx and extends
cephalad following the upper gluteal curvature. The eventual
scars will remain hidden in the gluteal cleft [6].
8.2.4 Skin Flap Dissection
The incision sites are infiltrated with 10 cc of 1 % lidocaine
with epinephrine 1:100,000. Tumescent fluid is injected into
the intramuscular and subcutaneous tissues, as well as the
areas to be suctioned. I approach one side at a time while
standing on the opposite side of the glutei to be worked on.
The incision is made down to the gluteal fascia (Fig. 25).
Using hooked retractors, the tissues are placed under upward
traction. The beginning of this dissection is tricky, because
the muscle fascia comes up relatively quickly and takes an
upward, sloping turn. Care must be taken not to enter the
muscle and lose the plane.
With the aid of deeper retractors, the dissection is contin-
ued, making sure to preserve the fascia on the muscle.
Preservation of the fascia on the muscle is key to this
approach to ensure that there is good closing tissue for
implant coverage. The dissection can be done with electro-
cautery or, for a less heated dissection, with a gauze pad
wrapped around the thumb, digitally elevating the subcuta-
neous tissues with an upward sweeping motion. The goal of
the initial subcutaneous dissection is to expose just enough
Gluteoplasty
Fig. 25 Incision is made down to the gluteal fascia
Fig. 26 Dissection at the gluteal midlevel
of the muscle and fascia to allow implant placement; this
usually means about 5–6 cm of subcutaneous dissection.
8.2.5 Muscle Dissection
Before beginning the dissection, it is important to understand
the anatomy. The major muscles in this zone are the gluteus
maximus, minimus, medius, and piriformis. The maximus
has transversely oriented fibers and is one of the largest mus-
cles in the body; its superior half covers the medius which
has vertically oriented fibers. The plane between these mus-
cles is more distinct in its superior portion (at the level of the
posterior superior iliac crest). However, as we move caudal,
the fibers integrate and become indistinguishable. Since our
dissection is performed at the gluteal midlevel, there will not
be clearly identifiable planes, muscle groups, or layers
(Fig. 26).
This is a blunt intramuscular procedure with some direct
visualization; the goal is to maintain a 2–3 cm muscle thick-
ness of coverage for the implant. The gluteus muscle has
about a 4–6 cm thickness, so that maintaining a 3 cm intra-
muscular dissection allows the muscle to remain and still
487
Fig. 27 Instrumentation
Fig. 28 Forcep dissection creates a small opening
provide coverage over the crucial nerves and vessels [11].
The midsacral level is used as the reference point, and the
fascia is opened following the direction of the muscle fibers
for a length of 4–5 cm.
The intramuscular dissection is started by using a long
hemostat and spreading perpendicular to the muscle for a
depth of one centimeter. At this point, the surgeon switches
to a ring forceps and continues the perpendicular muscle
spread for another 2 cm (total of 3 cm coverage). During the
forceps dissection, the surgeon will notice glistening fascia
fibers present at different levels of the dissection. If the 3 cm
depth has not been reached, the fascia is incised and dissec-
tion continues until the 3 cm mark is reached. The forceps
dissection creates only a small muscular opening which must
be enlarged (Figs. 27 and 28).
With the use of the cautery, the muscle incision is opened
medially and laterally to its full fascial incision length. Once
this depth has been reached, the Deaver retractors are intro-
duced on both sides of the muscle and spread. Up to this point,
the procedure has been relatively bloodless. The dissection
488
Fig. 29 Dissection is done in a sweeping, back and forth pushing
motion of the ring forceps
now becomes blunt and some blood loss is seen (about 50 cc).
It is important to remember that this is an intramuscular proce-
dure; there is no real areolar plane like in breast augmentation.
The closed ring forceps is used to bluntly push and create
the muscle pocket which should be kept at 3 cm thickness
throughout. It is best to start the pocket dissection in the
superior lateral direction. It is key in this portion of the dis-
section to take care to tilt the tip of the ring forceps down to
about 45° to counter the tendency to unconsciously tilt it
upward causing it to pierce through the muscle. If the muscle
is inadvertently pierced, it is okay to dissect deeper.
(Alternatively, this part of the implant can be converted to a
subcutaneous position, but deeper dissection is a better
option.) The dissection continues in a sweeping counter-
clockwise motion from the superior lateral to superior medial
direction using a back and forth pushing motion of the ring
forceps (Fig. 29).
Next, with a pocket partially created, the surgeon uses the
Aiche gluteal muscle dissector (serrated instrument) to fur-
ther define the pocket. This is done under direct visualization
and with the aid of retractors. If this dissector is not avail-
able, the surgeon can use an index finger or a curved Van
Buren sound to push the fibers. At this point, little dissection
will be done inferiorly. A lap pad is placed in the wound to
clear out any blood. No inferior dissection has been done to
this point – only lateral, superior, and medial dissection.
8.2.6 Tissue Expansion for Pocket Definition
To help define the pocket further, the surgeon places a breast
implant expander and overinflates it until no further expan-
sion can be obtained. The expander will stretch the muscle
and help to indicate areas that need further dissection. It will
also help define the inferior dissection (Fig. 30). In the past,
the inferior dissection was limited to an imaginary line that
spanned from the tip of the coccyx to the greater trochanter
of the femur; this limitation placed the implant in a very high
C. Mendieta
Fig. 30 Breast implant expander used to stretch the muscle
and unattractive position. As familiarity with this procedure
has grown, the inferior dissection has been refined so that it
extends 3–5 cm below the coccyx, placing the implant in a
more anatomic location with improved aesthetic contour.
To ensure safety, the inferior dissection is performed with
the expander in place; blunt finger dissection is used to push
muscle fibers away from the implant in an inferior direction.
Note, the majority of the inferior dissection is using finger
dissection; this way, muscle thickness is maintained and
instrument injury to any structures is avoided. On occasion,
some very dense and tough fibers that cannot be broken with
finger manipulation will be encountered. In these situations,
the expander is removed and these fibers are freed under
direct vision using the Aiche or Van Buren dissectors or even
cautery.
It is important to recall that the sciatic nerve is deeper
than the dissection. The ischial tuberosity is a great land-
mark to remember; this is easily palpated and sometimes
seen. Anatomically, if the ischial tuberosity can be palpated,
then the nerve lies in a groove that is immediately lateral to
this structure and is well protected. Occasionally, a surgeon
may encounter the inferior gluteal or superior gluteal arter-
ies; rarely are these cauterized or ligated. However, if
required, it is not a problem since the maximus is a type III
muscle with excellent blood supply. This dissection is rela-
tively bloodless.
8.2.7 Sizers/Implant Size
Once the surgeon is satisfied with the dissection, a sizer is
inserted to determine the appropriate implant to be used.
When the implant is in place, the muscle edges should be in
close proximity with very little tension at closure. This is one
of the key steps in the procedure (Fig. 31).
Every patient will exhibit different degrees of muscle
thickness and tightness; this is not related to athletic build or
body size. It is difficult to predict whose tissues will be lax or
tight. Therefore, it is often helpful to have a variety of sizers
Gluteoplasty
Fig. 31 Implant sizer is inserted to determine appropriate implant size
available in the operating room to help determine the largest
implant that this particular patient’s muscle will accommo-
date with minimal tension. Almost all patients can accom-
modate a small implant (250 cc), some a medium (300 cc),
and rarely a large (350 cc +). The muscle should have oppos-
ing kissing edges, meaning no tension whatsoever. Most
often, I use the smooth round implant to help prevent possi-
ble seromas later.
If I am injecting fat to add more volume to the muscle, I
perform the fat transfers through the incision using a 10 cc
Luer lock syringe on a 3 mm cannula. I transfer the fat with
repeated fanning passes into the superficial layer of the mus-
cle. Once I am satisfied with the volume and shape, I remove
the implant sizer and examine the pocket removing any free-
floating fat particles that may have escaped. I then irrigate
the pocket and continue with the procedure.
8.2.8 Drains
Once the implant size has been determined, a Jackson Pratt
drain is introduced in the pocket and brought out through a
separate stab incision in the infragluteal crease. Use of the
drain has decreased the incidence of seroma. At this point,
the pain pump can also be used. If catheters are placed, they
are brought out through the upper medial buttock or through
a small stab incision in the infragluteal crease.
8.2.9 Implant Placement/Closure
The implant pocket is irrigated with 10 cc of lidocaine 1 %
with epinephrine 1:100,000 mixed with 5 cc of Marcaine
0.5 % plain. All gloves are changed, the implant is soaked in
antibiotic solution, and the incision is wiped with Betadine.
A new sterile towel is placed over the buttock.
Next, the implant is rolled into a cigar shape and intro-
duced. A sterile sleeve may come with the implant, and this
is used to introduce the implant and help avoid implant con-
tact with the skin (be prepared to struggle). Sometimes, if the
muscle is tight, the surgeon will need to incise the muscle at
489
its insertion along the sacrum for about a ½ cm to create
more space (the surgeon should try to avoid having to do this
because it makes it more difficult to close).
Care is taken to leave a cuff of tissue so that it can be
closed over the implant. Any irregularities are corrected with
further pocket refinement utilizing a curved dissector. The
drains are checked for any kinking to be sure that they are in
a good position. The muscle is closed with 2-0 Vicryl. The
subcutaneous wound is closed in layers with a final running
3-0 Vicryl. The opposite side is now completed in a similar
fashion. The wounds are further reinforced with Dermabond
to help seal and prevent contamination later. The anal pack is
removed. An abdominal binder is placed around the gluteus
for pressure. If liposuction was done, a garment is placed
instead. The patient is taken to recovery in a supine position.
Once the patient is awake with a secure airway, she is placed
in the prone position. On discharge, the patient is instructed
to lie prone in the back seat of the car to avoid pressure on the
buttock.
The intramuscular placement described is a modification
of the Hidalgo gluteoplasty technique. Modifications include
adding liposuction to the flank, upper buttock, and occasion-
ally inner and outer leg; occasionally combining fat transfer
with the augmentation; using the double paramedian inci-
sion; lowering the extent of the inferior muscle dissection to
3–5 cm below the coccyx; using an expander to help create
the pocket; and using sizers for implant selection. There are
three key points to this operation:
1. Bilateral intergluteal paramedian incisions that start
1–2 cm below the tip of the coccyx and travel upward for
7–8 cm.
2. Preservation of gluteal fascia on the muscle during dis-
section to permit better purchase of the tissues during clo-
sure, limiting muscle dehiscence.
3. Selection of an implant of the proper size that has mini-
mal tension at closure so that the muscle edges are almost
kissing. This technical point has decreased muscle
dehiscence.
8.3 Postoperative Care
8.3.1 Activity
Since most wound dehiscences occur between days 12–16,
patients are instructed to minimize activities that cause wound
pressure or friction. For the first 3 weeks, they are asked to
sleep on their stomach, to lie on their stomach, or stand while
watching TV or reading. They are not to sit (except for bath-
room use). Sitting requires clearance from the surgeon.
Patients are evaluated on the third, seventh, and fourteenth
postoperative days. If on the 14th postoperative day the
wound is intact, the patient follow-up is 1 week later. At the
490
third postoperative week, patients are cleared for sitting and
driving and are encouraged to start stretching exercise. If the
wound is marginal, patients are followed closely, and they are
not allowed to sit or drive for at least 2 more weeks until the
wound appears stable or, if the wound dehisced, until granu-
lation tissue has developed in 2–3 weeks.
Patients may conservatively ambulate around the house
but are asked to limit their activities in order to avoid wound
friction/trauma. When traveling to the office, they are
instructed to lie prone in the back seat of the car.
Return to work is usually after 2–3 weeks.
Return to the gym will depend on wound status. If all is
well, patients can resume exercise 6 weeks postoperatively. If
the wound is compromised, they may have to wait 2–3 months.
After 3 months, patients are cleared for all types of activi-
ties (bungee cord jumping, motorcycles, etc.). In the begin-
ning, the implants will feel very firm (like sitting on rocks),
and it will take 3 months for them to soften. After that time,
they feel like a well-worked out buttock.
8.3.2 Garments
If liposuction was done, patients wear the traditional garments
for 4–6 weeks. If no liposuction was performed, an abdominal
binder is used for 2–3 weeks to place pressure in the upper part
of the buttock. This theoretically helps keep the buttock cheeks
together, hopefully decreasing wound tensions.
8.3.3 Drains
While drains are in place, the patient is kept on antibiotics
(ciprofloxacin or clindamycin). The drains are removed
when the output is less than 30 cc/day. They are usually not
kept for more than a week.
On occasions, the patient complains of increasing dis-
comfort or size in one buttock; in these cases, a percutaneous
syringe aspiration is performed with a 60 cc syringe and 18
gauge needle. If necessary, this is repeated several days later.
Since the implant is solid, there is no concern with rupture.
The skin has to be thoroughly cleaned with alcohol or some
skin disinfectant prior to needle insertion.
8.3.4 Postoperative Pain Management
Most of the discomfort occurs between days 3–10. The dis-
comfort is greatest in the early mornings, between 2 and
3 am. To help with the postoperative discomfort, I have
found Medrol dose packs and Neurontin 100 mg po bid to be
helpful. Muscle relaxants are also prescribed as well as anx-
iolytic medications. The pain pump will be most helpful in
the 2nd to 5th days. I also encourage patients to stretch to
help with the discomfort, and sometimes, walking will help.
Conclusion
In deciding whether to augment the gluteus with fat or
implants, we first need to determine how much fat is
C. Mendieta
available for transfer. In some patients, this question often
cannot be answered preoperatively since the quality and
quantity are not apparent until liposuction has started. To
make a difference with fat transfers, we need 300–800 cc
of fat per side. The actual volume will depend on patient
size, anatomy, and aesthetic goals. However, some gener-
alizations can be made; small-framed individuals will
require implants for gluteal augmentation; medium-
framed individuals present a dilemma since these patients
may not have enough donor fat and would require
implants. Patients that have a large or extra large frame
are best contoured and augmented through liposuction
and fat transfers.
In intramuscular implant augmentation, the size is
determined intraoperatively with the aid of sizers so as not
to create muscle tension at closure. Implant shape selec-
tion involves determining the muscle height-to-width
ratio; the tall buttock (2 to 1 height-to-width ratio) is best
augmented with the anatomic implant. The short buttock
(1 to 1 ratio) is best augmented with the round implant,
while the intermediate buttock (1–2 to 1 ratio) may require
the lateral view to make the final determination.
Complications have been tremendously decreased
from a 30–80 % wound dehiscence rate down to 6 %. This
was accomplished by following three principles: the use
of bilateral gluteal incisions, the use of sizers for proper
implant size selection, and finally, proper patient selection
through the use of body frame classification for procedure
selection. The operation has become safer, reproducible,
and hopefully more acceptable to physicians. These find-
ings are personal observations; other physicians may have
different experiences and may feel comfortable with
implant augmentations in the large- and extra large-
framed patients, but hopefully, this system will give some
guidance.
References
1. Bartles RY, O’Malley JE, Douglas WM, Wilson RG (1969) An
unusual use of the Cronin breast prosthesis: case report. Plast
Reconstr Surg 44:500
2. Cocke WM, Rickeson G (1973) Gluteal augmentation. Plast
Reconstr Surg 52:93
3. Gonzalez-Ulloa M (1991) Gluteoplasty: a ten-year report. Aesthetic
Plast Surg 15:85–91
4. Robles JM, Tagliapertra JC, Grandi M (1984) Gluteoplastia de
aumento: implante submuscular. Cir Plast Iberolatinoamer
10:365–375
5. De la Pena JA, Lopez-Momjardin H, Gamboa-Lopez F (2000)
Augmentation gluteoplasty: anatomical and clinical considerations.
Plast Cosmetic Surg 17:1–12
6. Mendieta CG (2003) Gluteoplasty. Aesthetic Surg J 23:441–455
7. Avendaño-Valenzuela G, Guerrerosantos J (2011) Contouring the
gluteal region with tumescent liposculpture. Aesthet Surg J
31:200–213
Gluteoplasty
8. Roberts TL, Mendieta CG (2004) Buttocks augmentation by
micro-fat grafting and implants. Proceedings of the American
Society of Aesthetic Plastic Surgery Annual Meeting. Vancover,
Canada
9. de la Peña JA, Rubio OV, Cano JP, Cedillo MC, Garcés MT (2006)
Subfascial gluteal augmentation. Clin Plast Surg 33:405–422
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10. Ali A (2011) Contouring of the gluteal region in women: enhance-
ment and augmentation. Ann Plast Surg 67(3):209–214
11. Hwang K, Nam YS, Han SH, Hwang SW (2009) The intramuscu-
lar course of the inferior gluteal nerve in the gluteus maximus
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361–365
 Male Genital Aesthetic Surgery
Giovanni Alei, Piero Letizia, and Lavinia Alei
1 Introduction
Since antiquity, doctors and surgeons have made countless
attempts to modify the shape and size of the penis, but the
first scientifically validated technique to correct curved penis
was defined only in 1965. In the following years the evolu-
tion of the surgery of the cavernous bodies has become
remarkable, expanding to include different new techniques
related to the correction of both the shape and size (espe-
cially in the most recent years) of the cavernous bodies. In
this chapter we analyze the most successful techniques
related to penis and testicular aesthetics. With regard to cav-
ernous bodies surgery, we must point out that when pursuing
an aesthetic result, the postoperative outcome needs to pre-
serve the function. This concept must be stressed not only
because of its semantic aspect but also because of its legal
importance.
2 Embryology and Anatomy
2.1 Elements of Embryology of Male
External Genitals
Until the seventh week of embryological development (the
undifferentiated phase of sexual development), external gen-
itals appear similar in both sexes. At the beginning of the
fourth week, mesenchyme proliferation produces in both
sexes the genital tubercle at the cranial extremity of the cloa-
cal membrane. On the sides of the cloacal membrane the
labioscrotal swellings and the urethral fold develop. At the
end of the sixth week, the urorectal septum merges with the
cloacal membrane, dividing it into an anal (dorsal) mem-
brane and a urogenital (ventral) membrane; within the sev-
enth week the two membranes break, creating the anus and
the urogenital opening. The testosterone produced by the
fetal testicles induces the masculinization of the genitals: the
genital tubercle grows and extends, creating the penis, and
the urogenital folds merge along the ventral surface of the
penis, producing the spongy urethra, whose external fusion
line represents the penile raphe. During the twelfth week, a
circular proliferation of the ectoderm appears at the glans
periphery to form the foreskin. The growth of the labioscro-
tal swellings, including their convergence and subsequent
fusion, forms the scrotal sac; the fusion line remains visible
in men, becoming the scrotal raphe, cranially consecutive to
the penile raphe and caudally next to the perineal raphe. Just
before birth the scrotal sac acquires the testicles (which orig-
inate in the abdomen and migrate to their definitive site after
the third month).
2.2 Anatomy of Male External Genitals
The penis is made up of three elongated formations: two cav-
ernous bodies and the spongy body, which contains the ure-
thra. We distinguish the distal extremity (glans), a mobile
portion (body or rod), and a proximal fixed portion (radix)
(Fig. 1).
The glans represents the distal extremity of the penis, and
is totally or partially covered by a skin fold when flaccid: the
foreskin. The glans surface appears smooth and pink; the
glans presents a conical shape with a large and oblique base
and a rounded top, where the external urethral orifice opens.
The base of the cone presents a bulging circular profile
(corona glandis) and is proximally delimited by a circular
furrow (balanopreputial furrow). On the glans ventral aspect,
along the middle line, we observe a skin fold (frenulum)
G. Alei, MD (* s 0 ,ETIZIA -$ s , !LEI -$
Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
e-mail: giovanni.alei@uniroma1.it
attached to a furrow. The frenulum joins the glans to the cor-
responding area of the foreskin, limiting its retractability
during erection. The foreskin is made of an external layer,

© Springer Berlin Heidelberg 2016 493

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_34
494 G. Alei et al.

Fig. 1 Anatomy. Sagittal section Pubic symphysis Prostate

Suspensory ligament
of the penis
Bulbo-
urethral
Corpus gland
spongiosum (Cowper)
of the urethra

Corpus
cavernosum Bulb-
cavernous
muscle
Glans
penis
Prepuce

Urethral meatus

Fig. 2 Anatomy. Frontal section Deep dorsal

of the rod vein of penis
Subcutaneous vein of Dorsal artery of
the penis penis
Skin
Colles' fascia

Buck's fascia
Deep artery
Tunica albuginea of the penis
of corpus
cavernosum Corpus
cavernosum

Urethra Corpus
spongioso
Tunica albuginea
of the spongy body
of the urethra

which represents the extension of the rod skin, and an inter-
nal layer originating from the folding of the external layer on
itself, fixed to the balanopreputial furrow; this double-layer
structure allows the elongation of the penis while avoiding
cutaneous traction. The cavernous bodies and the spongy
body (Fig. 2) are individually covered by a fibrous flexible
but non-expandable fascia, called the tunica albuginea. All
three bodies are surrounded by the thick Buck’s fascia from
which the intracavernous septum originates and, more super-
ficially, by loose connective tissue that forms Colles’ fascia,
proximally continuous to Scarpa’s fascia on the abdominal
wall.
The radix of the penis deepens into the anterior perineum
in the penile space; it is composed of the proximal portions
of the cavernous bodies (fixed to the ischial and pubis rami)
and the spongy body (fixed to the urogenital diaphragm).
Beneath the pubic symphysis, the three structures join to
form a unique cylindrical structure covered by skin, com-
monly defined as the body or rod.
The vascularization of the penis originates from the
pudendal artery (the terminal branch of the hypogastric
artery) from which the deep artery of the penis, the dorsal
artery, and the bulbourethral artery arise. The superficial
dorsal veins, which run externally on Buck’s fascia, and the
dorsal deep veins, which run directly below the same fascia,
ensure venous drainage. The pudendal plexus receives
venous blood that is conveyed to the hypogastric veins.
The cavernous or erectile tissue is made of blood-filled
spaces lined by endothelium and surrounded by fibromuscu-
lar contractile elements of smooth muscle, elastin, and
Male Genital Aesthetic Surgery
collagen. Blood from the arterioles reaches these spaces,
increases the volume of the cavernous body during erection,
and then is drained by the venules; these run out of the albu-
ginea through the corresponding foramina and are com-
pressed during erection to allow its maintenance
(veno-occlusive mechanism).
The penis is maintained in its site by the suspensory liga-
ment and the tendinous insertions of the pubocavernous
muscles. The suspensory ligament proximally inserts on the
anterior aspect of the pubic symphysis for its entire length,
and distally/dorsally inserts on the infrapubic penis tract,
which corresponds to the symphysis length and which is a
vertical fibroelastic bundle that then splits into two layers of
fibrous tissue surrounding the cavernous bodies. The bulbo-
cavernous muscle insertions remain lateral, 1 cm from the
inferior tract of the suspensory ligament.
The bulbocavernous muscles envelop the posterior part of
the urethral spongy body, surrounding both the urethral
spongy body and the penis cavernous bodies. Their action
allows elimination of the remaining urine drops after urina-
tion and determines, in addition to other physiological mech-
anisms, erection and ejaculation. From the medial aspect of
the ischial tuberosities and ischiopubic branches, two ischio-
cavernous muscles arise, which insert on (and cover) the root
of the cavernous bodies; their compression, after muscle
contraction, helps maintain erection.
3 Surgical Techniques
In this section we discuss the surgical techniques used to cor-
rect the main disorders affecting male genitals, with refer-
ence to plastic and aesthetic surgery. This type of surgery
allows not only to correct urethral orifice, foreskin, penile
rod, and testicle anomalies, but also to modify a normal anat-
omy, improving it also from a functional point of view.
3.1 Meatoplasty in Distal Hypospadia
Hypospadia is a deformity resulting from the altered connec-
tion of the urethral canal during embryonic development.
The external urethral orifice may appear in different ectopic
locations along the middle line on the penis ventral aspect,
from the glans to the perineum, presenting various morphol-
ogies (usually punctiform) but rarely obstructing urine flow.
In distal balanic hypospadias, the fan-shaped foreskin pres-
ents a cutaneous overabundance dorsally and laterally,
whereas it ventrally lacks skin, and in this bare area the ori-
fice may open; distal ectopic orifices most commonly do not
entail cavernous bodies, anomalies, or curvatures. Several
meatoplasty techniques have been illustrated to treat balanic
hypospadia [1], of which the most frequently adopted is dis-
495
cussed here. Fistulas are the most common complications
recurring in patients undergoing this procedure; these may
occur between the recreated urethral lumen and the penile
skin (because of minor resistance areas following the ure-
thral reconstruction), or anywhere the stitches slacken.
Another potential complication is stenosis of the neo-urethra,
possibly due to the inappropriateness of the cutaneous flap
created to reconstruct the urethra or to postoperative infec-
tions. The cutaneous retraction and the lack of elasticity
resulting from the postoperative scarring process frequently
reduce the length of the cutaneous flap and shrink it, compro-
mising the final result of the surgery. In any event, a high
percentage of recurrences often follow this type of
procedure.
3.2 Duckett’s Technique
The name of this technique derives from Meatal Advancement
'LANDULO 0LASTY )NTERVENTION -!'0) ;2, 3]. To be adopted,
this technique requires that the ectopic orifice be within 1 cm
from the apex of the glans and that the skin next to the meatus
be sufficiently movable to allow the urethra to be advanced.
After having created a traction point over the glans apex, an
access is obtained through a subcoronal ventral incision,
8 mm from the balanopreputial furrow (Fig. 3), exposing the
rod up to the penoscrotal junction. A vertical incision is per-
formed along the middle furrow from the distal edge of the
ectopic meatus proceeding for 1 cm to the glans apex, then
transversally suturing with a 6-0 suture. Using a skin hook
the ventral edge of the meatus is lifted and then moved for-
ward, thus creating an inverted V with the wings of the glans;
the edges of the glans are sutured, unifying them along the
middle line in the achieved position (Fig. 4); some subcuta-
neous stitches may be executed to facilitate the edges to con-
verge and to preserve symmetry. Next the middle raphe is
aligned, potential foreskin cutaneous overabundance is
resected, and the subcoronal access is sutured. In the case
that the ventral skin is not sufficient to be moved forward
with the meatus, the foreskin is vertically incised on its dor-
sal aspect and the resultant flaps (Byars’ flaps) are then ven-
trally transposed, paying particular attention to preserve
symmetry, thus avoiding future traction during erection.
3.3 Parameatal-Based Flap Technique
(Mathieu, Horton-Devine)
The so-called overturned flap (flip-flap) technique can be
adopted in cases of sub-balanic hypospadias, with a potential
but moderate recurvatum (easily recognizable after a phar-
macologically induced erection or, during surgery, through
hydraulic erection). After creating a traction point over the
496
Fig. 3 -EATOPLASTY $UCKETTS TECHNIQUE -!'0)  VENTRAL SUBCORONAL
access
glans apex and having marked the incision lines for a V flap
over the ventral aspect of the glans, an elliptical flap is set up
next to the ectopic urethral meatus; the incision is performed
along the entire balanopreputial furrow, 1 cm from the glans.
Thereafter the ventral margins of the glans are lifted up with
skin hooks, separating them from the underlying cavernous
bodies with the help of scissors. The V incision is performed
on the glans with a knife along the previously marked lines,
and the margins of the flap are then freed with scissors,
obtaining three flaps (one centrally and two laterally) from
the glans, all separated from the underlying structures. A 5-0
absorbable suture is produced on the central flap along the
middle line anchoring the glans to the tunica albuginea,
along with three internally knotted stitches with an absorb-
able 6-0 filament on the apex of the flap to fix it to the dorsal
margin of the meatus; a small V incision may be performed
on the meatus to make the flap margins fit with it. The proxi-
mal paraurethral portion of the elliptical flap is dissected,
G. Alei et al.
Fig. 4 -EATOPLASTY $UCKETTS TECHNIQUE -!'0)  SUTURING THE MAR-
gins of the glans
paying attention not to damage the underlying urethra, after
which it is flipped over, suturing its margins to the central
glans flap with an absorbable 6-0 filament. After having per-
formed a urinary catheterization, the margins of the glans
wings are juxtaposed and double-layer sutured to each other
with a 5-0 absorbable filament. Finally, the wings of the
glans are sutured to the ventral margin of the cleared
neo-meatus.
3.4 Preputial Vertical Island Flap Technique
(Scuderi)
The use of a pedunculated preputial flap was introduced for
the first time by Duckett [4] in the Island Flap technique; what
characterizes Scuderi’s technique is the ventral transposition
of the flap [5]. After having created a traction point over the
glans apex, an incision is performed along the entire balano-
preputial furrow, vertically going down to the ectopic meatus
and here making an elliptical incision around it. The skin of
the penis and the foreskin are lifted, cleaving Colles’ fascia
(tunica dartos) from Buck’s fascia; the urethra and the meatus
are separated from the cavernous bodies. The possible pres-
ence of a fibrous cord is evaluated through a hydraulic erec-
tion, and removed if necessary. After having positioned two
traction points laterally on the foreskin, a rectangular flap is
obtained from the dorsal skin of the penis, V-shaping its proxi-
mal margin. The flap is mobilized and a buttonhole incision is
made along the middle line of the peduncle (Fig. 5), paying
Male Genital Aesthetic Surgery
Fig. 5 Meatoplasty. Scuderi’s technique: buttonhole incision along the
middle line of the dorsal flap peduncle
Fig. 6 Meatoplasty. Scuderi’s technique: suturing the urethral margin
to the proximal portion of the flap
attention to preserve vascularization. Then the flap is ventrally
transposed, pushing the glans and the cavernous bodies
through the buttonhole previously created. A 5-mm incision is
made over the ventral wall of the urethra, along the middle
line, and the angle is sutured to the proximal portion of the flap
497
(Fig. 6) that is tubularized on the just positioned urinary cath-
eter. The suture of the flap margins closes the neo-urethra and
a middle incision is executed on the ventral aspect of the glans
to obtain two triangular flaps. The distal margin of the neo-
urethra is sutured to the distal edges of the glans flaps so that
the urethral meatus is recreated at the apex of the glans; the
distal portion of the neo-urethra is covered with the glans
flaps, suturing the flap margins to each other to recreate the
glans. Finally, the skin of the penis is sutured to the crown,
thus obtaining an aesthetic result similar to circumcision.
3.5 Postectomy
At birth, most infants show a physiological impossibility in
retracting the foreskin because of the natural adhesion
between the glans and the foreskin itself; the problem van-
ishes as the baby grows up and in any case at puberty; some-
times a medical intervention may be necessary, consisting in
a non-invasive lysis of the adhesions; this condition must be
distinguished from phimosis, which consists in stenosis of
THE PREPUTIAL RING 0HIMOSIS SHOULD BE DIVIDED INTO THREE DIF-
ferent grades of stenosis: in a grade I phimosis the phimotic
ring causes discomfort or pain only during the erection, in a
grade II phimosis the glans can barely be exposed, and in
grade III the foreskin does not allow the glans to be exposed
and quite often the urethral meatus cannot be seen. The phi-
mosis may be primary or secondary to inflammatory or trau-
matic processes. The surgical treatment of the phimosis
mainly consists in circumcision, which means the full
removal of the phimotic foreskin, exposing the glans both
during erection and also when the penis is flaccid. The out-
comes of this kind of surgery frequently include aesthetic
flaws and the reduction of glans sensitivity. From a func-
tional and aesthetic point of view, the ideal surgical treat-
ment is postectomy. This allows the glans to be partially
covered at rest and grants a higher sensitivity preservation,
sparing as much penile skin as possible.
In the cases of grade I and II phimosis, the postectomy sur-
gical technique consists in performing two circular incisions
under local anesthesia; both of the incisions are flute-beaked,
the first performed proximally and the second distally to the
stenotic ring. This expedient allows enlargement of the cir-
cumference of the following suture and prevention of a poten-
tial postoperative stenosis. The skin is isolated from the
underlying Colles’ fascia, which is dorsally incised and par-
tially removed. After having remodeled the internal and the
external layer, some interrupted (single) 3-0 absorbable
stitches are placed to suture the margins, starting from the four
cardinal points (to juxtapose the margins correctly). The only
technical difference in grade III phimosis relates to how the
internal layer is prepared: the preputial skin close to the glans
is dorsally and longitudinally incised at 12 o’clock. The
498
phimotic foreskin is then removed, preserving a 1-cm wide
preputial lamina that will be sutured to the untouched penile
skin, which was previously prepared by performing a flute-
baked incision on it, such as for grade I and grade II
phimosis.
3.6 Penis Straightening
Curved penis, or “recurvatum,” consists of an altered shape
of the erect penis, which appears curved on one or more
PLANES INSTEAD OF BEING STRAIGHT 0ENILE CURVATURES MAY BE
congenital or acquired. The curvature can be ventral, dorsal,
lateral, or mixed, and associated or not with urethral defor-
mities. Congenital penis curvatures are due to an abnormal
development of the cavernous bodies, the tunica albuginea,
or both. Over the years numerous surgical techniques have
been devised to correct curvatures.
3.6.1 Nesbit’s Technique and Variations (Nesbit
II, Kelami)
Nesbit [6, 7] described the first technique to correct penile
curvature in 1965. It consists in simply folding the tunica
albuginea with a non-absorbable continuous suture, per-
formed on the convex side of the curvature. The subsequent
variation, called Nesbit II, consists in the removal of ellipses
of the tunica albuginea from the convex aspect of the penis,
where the curvature of the cavernous bodies is more
Fig. 7 0ENILE STRAIGHTENING .ESBITS TECHNIQUE EXCISION OF THE TUNICA ALBUGINEA ALONG THE CONVEX ASPECT AND SUBSEQUENT SUTURE OF THE BREACH
G. Alei et al.
pronounced, thus shortening the convexity and correcting the
recurvatum. The technique includes the circumcision and the
entire scalping of the penis to its base.
Intraoperatively the surgeon decides on the number, the
dimensions, and the sites of the ellipses to be removed dur-
ing a hydraulic erection, applying some Allis clamps over
the albuginea to simulate the correction. After having
removed these clamps, the established portion of albuginea
is excised and the breaches are sutured (Fig. 7). The outcome
is verified with another induced erection, to proceed to
potential further corrections.
The aforementioned techniques are associated with a
25–30 % risk of recurrences, including the loosening of the
traction points or of the sutures. Unfortunately they also
cause a relevant shortening of the penis in cases of dorsal or
ventral curvatures. Further complications are the common
aesthetic flaws of the suture, consequences of the circumci-
sion, postoperative hematomas, adhesions affecting the
incised portion of the albuginea, and partial loss of glans sen-
sitivity, resulting from both the circumcision and the neuro-
logical lesions resulting after the scalping of the penile
sheaths to their base. Nesbit’s technique represents an
extremely simple and an easy-to-perform technique, which
is why, to date, it is still frequently adopted.
3.6.2 Devine and Horton Technique
In 1973, Devine and Horton [8] proposed a new technique
which still represents the only surgical solution to lengthen
Male Genital Aesthetic Surgery
the congenital shortness of the cavernous body (concave
side), whereas the other techniques refer to shortening its
length (convex side). This technique consists in incising the
concave aspect of the curvature (Fig. 8) and later suturing on
it a dermal patch of the proper dimensions to correct the
curvature.
3.6.3 Ebbehoj and Metz Technique
In 1979, Ebbehoj and Metz [9] proposed a technique consist-
ing in performing Z stitches on the convex aspect of the albu-
ginea: after having knotted the stitches they determine a
shortening, making the incision or the removal of albugine-
ous tissue unnecessary. This technique is simple and appro-
priate for moderate curvatures; several variations have been
proposed regarding both the suture materials and the kind of
stitches performed. This is an absolutely reliable technique
that allows completion of major corrections (obtained
through adopting other techniques) or correction of minor
curvatures.
3.6.4 Kelami’s Technique
In 1987, Kelami proposed a small variation of the Nesbit
technique. Kelami performed the excision of rhomboidal
portions of tunica albuginea (instead of elliptical por-
tions), horizontally suturing the breach with introflecting
stitches.
Fig. 8 0ENILE STRAIGHTENING $EVINE AND (ORTON TECHNIQUE INCISION ON
the concave aspect of the penis
499
3.6.5 Udall’s Technique
In 1980, Udall [10] proposed a technique to correct dorsal
curvatures, which allowed lengthening of the dorsal aspect
of the penis by means of a transversal incision and longitudi-
nal suture.
3.6.6 Montague’s Technique
In 1989, Montague proposed the excision of a unique loz-
enge of the albuginea, involving both the cavernous bodies,
after the prior preparation of the dorsal nervovascular bundle
of the penis. This is carried out starting from two lateral,
paraurethral incisions (right and left) and allows correction
to be obtained while limiting penile shortening owing to the
isolation of Buck’s fascia and all its elements [11].
3.6.7 Yachia’s Technique
In 1990, Yachia [12] proposed a variation of the Nesbit tech-
nique after having noticed that this procedure caused a high
percentage of erectile dysfunctions because of the scar tissue
THAT DEVELOPED OVER THE CAVERNOUS BODIES 0ERFORMING LONGI-
tudinal incisions and suturing them horizontally, according
to the Heineke-Mikulicz principle, the longest side of the
tunica albuginea may be shortened. The longitudinal inci-
sions are parallel to each other and distant from both the neu-
rovascular bundle and the spongy body, reducing the risk of
damaging these structures which, furthermore, do not need
intraoperative mobilization.
3.6.8 Alei’s Technique
In 1990, Alei for the first time presented his own technique
to correct curvatures without coronal incision or circumci-
sion. This procedure consisted of a dorsal, or ventral, access
at the base of the penis, without any aesthetic flaw, neither
for the penile sheaths nor in terms of sensitivity [13]. In this
technique a preoperative careful measurement is essential to
predetermine the position and the dimensions of the corporo-
plasty that is to be performed, because during the surgery the
penis is flaccid and the hydraulic erection is used only as an
intraoperative check. This technique appears peculiar
because it allows avoidance of circumcision and scalping
and, moreover, intervention on the penis at rest on preopera-
tively determined points during a pharmacological erection.
In both dorsal and ventral curvatures, the asymmetry of the
suture (the overlapping of the flaps is greater in the middle
and minor laterally of the penile rod) allows correction of the
recurvatum with minimum shortening. The operation starts
with a penoscrotal incision (of about 3 cm) in cases of dorsal
recurvatum, and with an incision over the pubopenile arch in
cases of ventral recurvatum. After the “degloving” is com-
pleted, and a lace is placed at the base, Buck’s fascia is pre-
pared at the sites where the correction will be realized. The
tunica albuginea is transversally incised on the predeter-
mined points separating it from the underlying cavernous
500
Fig. 9 0ENILE STRAIGHTENING !LEIS TECHNIQUE INCISION OF THE TUNICA ALBU-
ginea and subsequent separation from the underlying cavernous tissue
tissue, thus obtaining two flaps, a proximal and a distal flap
(Fig. 9), which are superimposed on each other, and double-
breasted sutures performed with single stitches with a 2-0
absorbable filament. It is important to apply these stitches
asymmetrically so as to be able to superimpose a greater por-
tion of tissue over the point of maximum curvature (Fig. 10).
Now, by inducing a hydraulic erection, it is possible to evalu-
ate the achieved correction. Next a continuous suture of the
free flap is performed over the albugineous plane with a 2-0
absorbable filament, both to grant a better hydraulic tight-
ness and to strengthen the corporoplasty. A 2-0 silk stitch is
applied on the point of maximum traction of the corporo-
plasty to reduce the risk of recurrence after a potentially
rapid reabsorption of the underlying sutures.
Compared with the other techniques, this procedure is
associated with a minor rate of recurrence (4 % of a total num-
ber of 310 patients) because it does not commit the approach
G. Alei et al.
Fig. 10 0ENILE STRAIGHTENING !LEIS TECHNIQUE SUTURE WITH ASYMMETRI-
cal superimposition of the margins, thus to obtain the maximal correc-
tion on the point of extreme traction. Numbers 1–4 represent the
progressively decreasing quantity of albuginea tunica flaps to be over-
lapped from the most medial point (1) to the periphery (4)
of the incisions to the sutures; rather, it welds the dissected
albugineous flaps superimposing them, obtaining greater
solidity and physical resistance to the lengthening of the albu-
ginea during the erection. Thanks to the asymmetrical suture,
a relevant reduction of the shortening (such as in the corporo-
plasty described by Montague) and a lack of iatrogenic pares-
thesia or anesthesia is observed because of the degloving
without scalping. The healing time and the number of medica-
tions are considerably reduced, owing to the low surgical
accesses and the subsequent lack of postoperative edemas and
pain. However, Alei’s technique entails longer operative times.
3.7 Penile Lengthening
0ENILE ENLARGEMENT SURGERY WAS INITIATED TO TREAT CONGENITAL
penile brevity [14]; over time there has been an increasing
demand for this type of surgery for aesthetic or functional
reasons, even in the presence of a normal penile anatomy
[15] (Fig. 11). It is essential to distinguish between balanced
reasons and requests based on a dysmorphophobia, which is,
however, quite common. It is absolutely inadvisable to pro-
ceed to surgery if the psychosexological interview brings to
light personality disorders (psychosis or neurosis focused on
the genitals), or if serious disorders of a sexual nature in the
presence of a normal anatomy.
Male Genital Aesthetic Surgery
Fig. 11 0ENILE LENGTHENING 4ECHNIQUE BASED ON THE DISSECTION OF THE SUSPENSORY LIGAMENT AND ON THE POSITIONING OF !LEIS PUBOCAVERNOUS
space-maintainer
0ENILE
LENGTHENING SURGICAL TECHNIQUES ARE BASED ON 3.7.1 Suspensory Ligament Incision Technique
the incision of the suspensory and fundiform ligaments,
on lipectomy or pubic liposuction, and on advancing the
skin with cutaneous flaps. Depending on the case, a good
aesthetic and functional outcome may be achieved by
adopting a single technique or a combined approach.
Rarely the use of advancement flaps can be adopted as the
sole procedure, but more commonly it is combined with
other techniques. The V-Y advancement represents the
most popular approach, having numerous variations
related to the site and the extension of the incision.
However, wide V-Y flaps are associated with a high risk
of hypertrophic scarring and genital deformities: penile
scrotalization with reduction of its dimensions and dete-
rioration of sexual activity.
It is important, therefore, that the incision be as short as
possible and properly distant from the pubopenile junction.
All sovrapubic incisions are accompanied by the risk of
hypertrophic scarring due to the partial loss of the flap, inap-
propriate suture, extreme tension over the flaps, and dealign-
ment of the margins.
501
The suspensory ligament maintains the root of the penis
proximal to the anterior aspect of the pubic symphysis
orienting up the penis, obliquely, during the erection. The
surgical incision of the suspensory ligament allows the
surgeon to distance the infrapubic penis from the
symphysis (Fig. 12), releasing the penile structures and
reducing the elevation angle of the penis during erection;
it simultaneously lowers the point where the penis origi-
nates from the pubis and elongates the initial length by
20–30 %.
The procedure entails a 2- to 3-cm long V incision that
has its apex on the middle of the pubopenile arch. After hav-
ing incised the subcutaneous tissue, Scarpa’s fascia is pre-
pared on the right and the left in respect to the fundiform
ligament until it is fully unveiled to be dissected; the suspen-
sory ligament is detected below the fundiform ligament
(Fig. 13), the adipose tissue is laterally separated from the
latter, which is dissected with surgical scissors along the
anterior aspect of the pubic symphysis in a poorly bleeding
area.
502
Fig. 12 0ENILE LENGTHENING 4ECHNIQUE BASED ON THE DISSECTION OF THE
suspensory ligament: the incision of the ligament allows to distance the
infrapubic penis from the symphysis
Fig. 13 0ENILE LENGTHENING 4ECHNIQUE BASED ON THE DISSECTION OF THE
suspensory ligament: preparation of the ligament before its dissection
G. Alei et al.
This technique is frequently associated with recurrence
caused by rapprochement of the dissected ligament
margins, with the aesthetic-functional result being nega-
tively affected by reshortening of the penis due to
scarring.
3.7.2 Suspensory Ligament Incision
and Pubocavernous Space-Maintainer
Positioning Technique
In 1997, Alei proposed a variation of the penile-lengthening
technique, which avoids the margins of the incision to be
reconciled. After having dissected the suspensory ligament,
the just created neo-cavity between the symphysis and the
cavernous bodies is used to insert the pubocavernous dilator
(the space-maintainer).
To assemble the space-maintainer, a soft silicone block is
incised according to the angle formed by the cavernous bod-
ies with the pubic symphysis, following the neo-cavity mea-
surements. After having carved out the wedge, a concave
surface is shaped. It then will face the dorsal convex aspect
of the cavernous bodies and the proximal concave aspect that
will fit with the concave aspect of the pubic symphysis. Next,
the space-maintainer is fixed to the pubic symphysis perios-
teum by four polypropylene 0 stitches (Fig. 14). A Redon
drain is placed and left for the first 12–24 h. The surgery ends
with the closure in layers with a 2-0 absorbable filament and
Y-suturing the skin with a 3-0 silk filament. If pubic hypera-
diposity is present, it is necessary to perform a pubic
lipectomy.
3.7.3 Pubic Lipectomy and Liposuction
0ATIENTS AFFECTED WITH PUBIC HYPOSPADIA PRESENT A PECULIAR
kind of penile shortness. This particular anatomic conforma-
tion often occurs in the presence of hyperadiposity and trun-
cated cone-shaped pubis that partially or totally hides a
normal-sized penis. This condition is related to severe psy-
chological discomfort because of the penile shortness, often
associated with a penetrative limitation because of the pubic
ADIPOSE PAD INTERPOSITIONING ,IPECTOMY IS PERFORMED
through a lozenge transverse incision, whose upper margin
should correspond to the upper limit of the hyperadiposity,
while the inferior margin is V-incised above the pubopenile
arch to lengthen the skin adequately (Fig. 15). After having
deepened the incision of the supra-aponeurotic adipose tis-
sue, this is completely excised; after a proper hemostasis,
two drains are placed, and the skin and the subcutis are
T-sutured.
In cases of minor hyperadiposities, a less invasive
approach could be adopted through liposuction.
Complications following pubic lipectomy or liposuction
exactly coincide with those occurring after the same tech-
niques performed in different anatomic locations: hemato-
mas, seromas, hollows, infections, and necrosis.
Male Genital Aesthetic Surgery 503

Fig. 14 0ENILE LENGTHENING

Technique based on the dissection of
the suspensory ligament and on the
positioning of Alei’s pubocavernous
space-maintainer: the space-
maintainer is positioned;
performance of the four anchoring
stitches. Arrow indicates the
downshifting of the penis from its
original position after surgery

3.8 Penis Enlargement
0ENIS ENLARGEMENT TECHNIQUES AIM AT INCREASING THE ROD
diameter. Demands for penile enlargement come from
patients presenting a micropenis and a normal-sized penis. In
the case of a normal-sized penis the reason may be related to
a lack of sensitivity during the penetrative act; this discom-
between Colles’ and Buck’s fascia, but can be placed under
the neurovascular bundle if the skin is insufficient. Finally
Colles’ fascia and the incision used for the access are sutured;
a compressive dressing is maintained for 7–10 days, and the
use of a vacuum device (twice a day for 6 months) is required
to avoid penile retraction. Usually this technique allows
enlargement of the penis circumference of 3.15 cm.
fort affect both the patient and his partner. History is replete
with techniques attempting to achieve penile enlargement;
we discuss here the more recent acquisitions.
3.8.1 Enlarging Technique Using Scaffolds
(Perovic)
0OSTOPERATIVE COMPLICATIONS THAT MAY OCCUR ARE INFECTION
partial necrosis of penile skin, and seroma.
3.8.2 Enlarging Technique Using
Dermal Matrix (Alei)
0ENILE ENLARGEMENT THROUGH POSITIONING OF BIOLOGICAL MATERI-
)N  0EROVIC ET AL ;16] illustrated his enlargement tech-
nique using biodegradable scaffolds. In this procedure, the
patient previously undergoes the excision of a small ellipti-
cal skin portion under local anesthesia; a 0.5- to 1.0-cm3
portion of dermis is obtained, and then cultured and expanded
to reach a cellular proliferation of at least 2 × 107 (this takes
3–5 weeks). The obtained autologous fibroblasts are used to
inseminate previously treated tubular scaffolds. The surgical
reimplantation technique entails a subcoronal incision along
the whole penile circumference and the scalping of the cav-
ernous bodies; to avoid circumcision this access entails, an
alternative longitudinal ventral incision may be performed to
reach the penile eversion. Two longitudinally opened tubular
scaffolds are placed to dress the rod; they are usually placed
als has been further simplified by Whitehead’s technique.
This approach entails the use of human dermal matrix sheets
(Alloderm), which allow the proliferation of the autologous
dermis, granting a durable result affected by minimal compli-
cations. The growth, represented by the Alei technique, keeps
the foreskin intact because of the unique access at the penis
base, and enhances the final aesthetic outcome, ensuring a
circumference growth equivalent to a 20 % increase in com-
parison with its initial value [17]. A dorsal transverse incision
of about 2 cm is performed at the base of the penis (Fig. 16)
and, after having carefully prepared Colles’ fascia (Fig. 17),
the degloving is carried out (Fig. 18). Maintaining the penis at
its maximal traction, one or two Alloderm sheets are placed
over Buck’s fascia to cover the cavernous bodies with a single
504 G. Alei et al.

Fig. 15 0UBIC LIPECTOMY )NCISION WITH A 6 SHAPED INFERIOR MARGIN TO

allow the following Y-suture

layer of sheets, leaving the spongy body of the urethra uncov-

ered. Then the perimeter of the patch is sutured to Buck’s
fascia with a slow absorbable 2-0 filament, leaving a matrix
surplus between the stitches to allow their extension during
erection. In the end, the penile structures are repositioned to
their sheaths (Fig. 19), and Colles’ fascia and the skin are
sutured with single stitches. A urinary catheter has to be
maintained for the first 24 h, Redon drains are maintained for
12–24 h, and compressive dressing is maintained for
10–12 days. The patient will be able to regain sexual activity
1 month after surgery. Although, to date, the best results are
related to the use of Alloderm, Alei’s original technique may
be modified using dermal matrices of diverse origin.
3.8.3 Injectable Material Techniques
Lipofilling
This technique entails taking the autologous fat through
abdominal liposuction and its subsequent reinjection into
Colles’ space (between the Buck’s and the Colles’ fascia). In
the literature, the reported average values describe a circum-
FERENCE ENLARGEMENT OF ABOUT  CM INJECTING n M, OF
INJECTABLE SILICONE HAS BEEN USED IN SYNTHETIC lLLING
fat (depending on the anatomic situation). Although this
technique appears simple and non-invasive, it is associated
with frequent postoperative complications resulting from the
inadequate blood supply and breakage, reabsorption, or
migration of the injected adipocytes. Thus an unsatisfactory
Fig. 16 0ENILE ENLARGEMENT %NLARGING TECHNIQUE WITH DERMAL MATRIX
(Alei): transverse dorsal incision for the access at the base of the penis.
(a) Skin incision, (b) preparation of Colles’ fascia
aesthetic result is quite often apparent, with the appearance
of nodular formations that may contain liquid, necrotic, or
calcific material, in addition to penile asymmetry. It is also
important to consider that, as a consequence of the fat injec-
tion the layer of adipocytes may seriously soften the rigidity
of the cavernous bodies, resulting in a disappointing erection
to both the patient and his partner.
Silicone Filling and Hyaluronic Acid Filling
,IQUID
procedures, while hyaluronic acid injectable gel is a biologi-
cal filler.
The injection for aesthetic reasons of liquid silicone to
augment the volume of tissues has been used since the 1940s.
!S INlLTRATION WITH SMALL QUANTITIES UP TO  M, IN
Male Genital Aesthetic Surgery 505

Fig. 17 0ENILE ENLARGEMENT %NLARGING TECHNIQUE WITH DERMAL MATRIX

(Alei): preparation of Colles’ fascia using round scissors

Fig. 19 0ENILE ENLARGEMENT %NLARGING TECHNIQUE WITH DERMAL MATRIX

(Alei): on suturing the patch, the penile structures are replaced in their
sheaths

multiple sites are insufficient to enlarge the penile circumfer-

Fig. 18 0ENILE ENLARGEMENT %NLARGING TECHNIQUE WITH DERMAL MATRIX
(Alei): degloving of cavernous bodies
ENCE MUCH GREATER QUANTITIES OF SILICONE n M, ARE
required. Despite the fact that surgeons in some countries
still perform penile enlargement with liquid silicone, this is
absolutely inadvisable because of the migration of the
injected material that frequently leads to considerable penile
asymmetries. The injection often causes edemas and granu-
lomas of relevant dimensions. Furthermore, there is a risk of
lesions affecting blood vessels and nerves, which may poten-
tially lead to a loss of sensitivity and erectile dysfunction.
Gels containing hyaluronic acid are used for glans
enlargement; an augmentation of the glans circumference up
to 1.5 cm may be obtained by injecting 2 cm3 of hyaluronan.
Although this procedure is seldom adopted, no relevant com-
plications have been reported thus far.
506
3.9 Testicular Prosthesis Implantation
The implantation of a testicular prosthesis is indicated in dif-
ferent cases [18], both for aesthetic reasons and, in some
cases, psychosexological reasons after orchiectomy or in
monorchidism conditions, both congenital or iatrogenic.
Testicular prostheses simulate the real form, dimensions,
weight, and consistency of testicles. They have an ovoid
shape, may be internally made of silicone, silicone gel, or
saline, and are available in several sizes. Every prosthesis has
a plate at its apex, presenting a buttonhole, which allows the
surgeon to fix the prosthesis internally to the scrotal bag and
G. Alei et al.
nally incised, forcing out the liquid (typically a transparent,
yellow liquid) contained between the two sheets. Then the
exceeding portion of the tunica vaginalis, overextended by
the spilling, is excised, maintaining about 2 cm around its
reflection zone over the testicle. The incised margins are
sutured with single stitches or continuous absorbable sutures.
The serous flap is everted and sutured behind the didymus
and around the funicle, thus avoiding the reformation of a
closed cavity in which the hydrocele may recur. The surgical
breach is sutured with non-absorbable single stitches, being
careful to place them distantly from the suture margin to
allow hemostasis.
thus avoiding its dislocation. The implantation of the testicu-
lar prosthesis may be performed even in children and adoles-
cent patients [19], considering that it will be necessary to
substitute the prosthesis at the end of the patient’s develop-
ment. Rarely, the hemiscrotum cannot host a prosthesis
because of its limited dimensions; in this case, a tissue
expander may be first implanted and then substituted with
the prosthesis of the proper size.
The most common implantation technique, which is also
associated to the best aesthetic outcomes, consists in a longi-
tudinal middle incision on the anterior aspect of the hemis-
crotum (an inguinal access is often preferred in pediatric
patients), except in the case where a different access is neces-
sary (but nevertheless usable to implant the prosthesis) to
treat the primary pathology. Once the incision is made, a
space inside the scrotal bag is created with the help of a fin-
ger or a Foley catheter balloon to place the prosthesis. The
scrotal wall is everted and the buttonhole of the prosthesis is
fixed with a non-absorbable inert stitch to the dartos, to avoid
the dislocation of the implant. The testicular skin is sutured
with a silk filament, avoiding anti-aesthetic and easy-to-
infect sutures.
The postoperative complications are the same as those
related to any other prosthetic implantation. Infections occur
but are rare. The implanted prosthesis may break because of
wrong positioning or a subsequent dislocation, or the break-
age may follow a violent impact, but it may even be related
to the fragility of aged implants or other causes. These com-
plications may require reoperation to remove or substitute
the implant.
3.10 Hydrocelectomy
A hydrocele is serum spilling into the cavity delimited by the
testicular vaginal tunica propria. The most common surgical
technique adopted to treat this condition is resection, fol-
lowed by eversion, of the tunica vaginalis; an anterior trans-
versal incision is performed over the affected hemiscrotum,
thus to expose the testicle and its involucres. The external
tunica vaginalis (also called the parietal layer) is longitudi-
0OSTOPERATIVE COMPLICATIONS AFTER A HYDROCELECTOMY
though infrequent, are infections and pain in pediatric
patients, while in adults hematomas and pain represent the
most common complications. By placing a compressive
dressing and a drain for 24 h, it is possible to reduce the risk
for these complications. The technique entailing the excision
and eversion of the testicular vaginalis is poorly correlated to
any complications, whereas they much more frequently
occur in cases where other techniques are employed.
4 Authors’ Favored Techniques
The high number of aesthetic issues regarding male genitals
and the numerous existing surgical techniques has imposed
on us the need to select, throughout the previous paragraphs,
our favored techniques. This selection derives both from our
personal experience and from a careful evaluation of the
international literature dealing with the invasiveness and
complexity of the surgical procedures on the basis of the
potential aesthetic outcomes and risks of recurrence/
complications.
5 Complications
Depending on the technique and the materials used, all post-
operative complications have been considered for each surgi-
cal technique discussed. We particularly highlighted the
events that, differing from general surgical complications,
may potentially interfere with the surgeon’s performance
and frustrate surgical outcomes.
6 Informed Consent
Over the years the medicolegal discipline has reaffirmed the
importance of giving complete information to patients before
they undergo medical or surgical treatment that may repre-
sent a risk as regards patient safety, complications, and
adequate outcomes. The acquisition of the informed consent
Male Genital Aesthetic Surgery 507

requires the patient to be correctly and adequately informed
about his health conditions, the characteristics of the pathol-
ogy he is affected by, and his perspectives and therapeutic
options. The way this interaction is established between the
patient and the doctor requires a full explanation of patholo-
gies and treatments, which should be apposite to the patient’s
age, culture, comprehension capability, and mental state. To
limit the acquisition of the informed consent to a mere signa-
ture over a preprinted module represents deontologically
incorrect behavior and, furthermore, exposes the profes-
 $UCKETT *7 3NYDER (- RD  4HE -!'0) HYPOSPADIAS
repair in 1111 patients. Ann Surg 213(6):620–625, discussion
625–626
4. Duckett JW Jr (1980) Transverse preputial island flap technique for
repair of severe hypospadias. Urol Clin North Am 7:423
5. Scuderi N, Chiummariello S, De Gado F (2006) Correction of
hypospadias with a vertical preputial island flap: a 23-year experi-
ENCE * 5ROL  0T  n
6. Nesbit RM (1965) Congenital Curvature of the phallus: report of
three cases with description of corrective operation. J Urol
93:230–232
7. Kelâmi A (1987) Congenital penile deviation and its treatment with
the Nesbit-Kelâmi technique. Br J Urol 60(3):261–263
sional to legal actions in cases of complications that were not  $EVINE #* *R (ORTON #%  3URGICAL TREATMENT OF 0EYRONIES
fully defined and illustrated. disease with a dermal graft. J Urol 111(1):44–49
The correct information given to the patient should describe
the diagnosis, the chosen treatment, the typical and atypical
complications of this treatment, and the risks it entails. Both
during the information phase and while drawing up the con-
sent, continuous reference must be made to the procedures and
complications previously described throughout this chapter on
single techniques. Furthermore, it is important to inform the
patient about all the potential therapeutic options that could be
adopted in his case, regardless of the surgeon’s preferences.
Considering the importance of the genitals and, in partic-
ular, of the penis on a psychological level, in most cases it
should seem opportune to support the informative phase of
the patient with a psychosexological counseling. The evalua-
tion of the candidate’s appropriateness to aesthetic surgical
procedures should pay particular attention to which expecta-
tions the patient has and if these can be effectively achieved.
 %BBEH’J * -ETZ 0  #ONGENITAL PENILE ANGULATION "R * 5ROL
60(3):264–266
10. Udall DA (1980) Correction of 3 types of congenital curvatures of
the penis, including the first reported case of dorsal curvature.
J Urol 124(1):50–52
11. Daitch JA, Angermeier KW, Montague DK (1999) Modified corpo-
roplasty for penile curvature: long-term results and patient satisfac-
tion. J Urol 162(6):2006–2009
12. Yachia D (1994) Our experience with penile deformations:
incidence, operative techniques, and results. J Androl 15(Suppl):
63S–68S
13. Alei G, Danti M (1990) The surgical treatment of penile curva-
ture: a modified Nesbit procedure. Int J Impot Res 2(Suppl 2):
431–432
14. Vardi Y, Gruenwald I (2009) The status of penile enhancement pro-
cedures. Curr Opin Urol 19(6):601–605
15. Vardi Y, Har-Shai Y, Gil T, Gruenwald I (2009) A critical analysis
of penile enhancement procedures for patients with normal penile
size: surgical techniques, success, and complications. Eur Urol
55(4):1002
 0EROVIC 36 "YUN *3 3CHEPLEV 0 $JORDJEVIC -, +IM *( "UBANJ
T (2006) New perspectives of penile enhancement surgery: tissue
Acknowledgement We thank Dr. Francesco Ricottilli for his contribu-
engineering with biodegradable scaffolds. Eur Urol 49(1):
tion with this work.
139–147
 !LEI ' ,ETIZIA 0 2ICOTTILLI & 3IMONE 0 !LEI , -ASSONI & 2ICCI 3
(2012) Original technique for penile girth augmentation through
porcine dermal acellular grafts: results in a 69-patient series. J Sex
References Med 9(7):1945–1953
18. Bodiwala D, Summerton DJ, Terry TR (2007) Testicular prosthe-
 "RAGG 47 !LI 3. 7ARNER 2 0ARK !*  (YPOSPADIAS SURGERY
in plastic surgery: a snapshot of today with an eye on tomorrow.
* 0LAST 2ECONSTR !ESTHET 3URG  n
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dure for subcoronal hypospadias. Urol Clin North Am 8(3):513–519
ses: development and modern usage. Ann R Coll Surg Engl
89(4):349–353
19. Rose M, Aberg M, Bohn J (2008) Testicular prosthetic implants in
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0LAST 2ECONSTR 3URG (AND 3URG  n
 Aesthetic Surgery of the Female
Genitalia
Malcolm A. Lesavoy and Catherine Huang Begovic
1 Introduction
The first cosmetic vaginal surgery was reported in the litera-
ture by Hodgkinson and Hait in 1984 [1]. Recently, there has
been an increased interest in cosmetic surgical procedures of
the female genitalia [2–5]. The National Health Service
(NHS) reported a doubling of the number of labia reductions
carried out in the UK in 2004 compared to 1998 [6].
The indications for labia reduction are generally orga-
nized in the literature by three categories – women who
suffer from physical or functional complaints associated
with a genital abnormality, women without physical com-
plaints but want surgical intervention for cosmetic reasons,
and women who seek surgery for both functional and aes-
thetic reasons [7]. In the physical complaint group, several
specific complaints were vulvar pain and irritation riding a
bike, horseback riding, wearing tight underwear or clothes,
and superficial dyspareunia. Enlarged labia can signifi-
cantly impair a woman’s quality of life – causing constant
irritation, difficulty maintaining hygiene, discomfort or
embarrassment with clothing, and impairment or pain with
exercise or sexual activity [8, 9]. Many women feel emo-
tional embarrassment with enlarged labia. Women often
compare themselves with others and protrusion of the labia
minora past the labia majora is considered by many women
to be unattractive [10]. Miklos et al. found that 93 % of
patients sought surgery for purely personal reasons and
7 % admitted to being influenced by a male of female part-
ner, spouse, or friend [7].
M.A. Lesavoy, MD, FACS (*)
Private Practice, Encino, CA, USA
e-mail: drlesavoy@aol.com
C. Huang Begovic, MD, FACS
Private Practice, Beverly Hills, CA, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_35
2 Embryology and Anatomy
The external female genital organs include the mons pubis, the
labia majora and minora, the clitoris, and the vestibule of the
vagina. The mons pubis is the fatty tissue on top of the pubic
symphysis that forms a round prominence and is covered by
hair. The labia majora are paired cutaneous longitudinal folds
that extend from the mons pubis to the perineum. Each labium
has an outer, pigmented surface and an inner smooth surface
covered with sebaceous follicles. The labia minora are also
paired cutaneous folds medial to the two labia majora that
begin at the clitoris, extend posteriorly along the orifice of the
vagina, and end at the posterior edge of the labia majora.
Anteriorly, the labium minora divides into an anterior and pos-
terior fold. The anterior fold passes anterior to the clitoris
forming the clitoral hood and the posterior fold passes poste-
rior to the clitoris forming the clitoral frenulum. The clitoris is
an erectile structure situated between the two folds of the labia
minora and is homologous to the penis.
3 Surgical Techniques
3.1 Labia Minora Reduction
Labia minora hypertrophy is variable but has been defined as
labia with a longitudinal length longer than 4 cm [11, 12].
Ideally the labia should protrude slightly past the introitus at
about 1 cm [13]. In practice, there are wide variations in
female genital anatomy and what is normal should be defined
by the patient (Fig. 1). Traditionally, labia minora reductions
have been performed by trimming the labial edge and then
oversewing the cut edge [5, 14–16]. This technique was
described by Girling in Plastic and Reconstructive Surgery
in 2005. The tissue that protrudes beyond the labia majora is
excised and the internal and external edges of the labia are
sutured [17]. Before suturing, if there is a disproportion or
step-off between the clitoral hood and the newly sized labia
509
510
Fig. 1 Normal variations in labia. Patients differ in labia minora length, thickness, symmetry, and clitoral hooding
minora, parts of the hood are removed on both sides of the
clitoris before the incision is closed [12]. To avoid a continu-
ous scar, another surgeon performed a running W-shaped
resection from the frenulum to the posterior fourchette
instead of a straight curved line [9].
In 1998 Alter described a labia minora reduction tech-
nique using a central wedge or V excision of the most pro-
tuberant portion of the labia with re-approximation of the
anterior and posterior edges. This technique preserves the
normal edge and places the scar line on the inner and outer
surface of the labia instead of along the edge. The wedge is
excised to create a straight line along the length of each
M.A. Lesavoy and C. Huang Begovic
labium with no tension on the suture line. This reduced the
vertical dimension of the labia minora but not the superfi-
cial excess. The inner wedge is designed as V extending
medially into the vagina while the outer wedge is curved
lateral and anterior to excise any excess labium and clitoral
hood. The inner and external V are shaped differently. In
1998 Alter removed the entire wedge but in 2008 modified
this technique to remove only the mucosa and outer skin
while attempting to keep most subcutaneous tissue – excis-
ing only what is necessary to produce a good cosmetic
result [18]. An adaptation of this technique by Giraldo et al.
[19] involves cutting two 90° Z-plasties on the internal and
Aesthetic Surgery of the Female Genitalia
external surface to make an irregular wedge shape. They
believe this pattern results in an improved functional and
aesthetic result. Munhoz et al. [20] described an inferior
wedge excision instead of the central wedge described by
Alter. The anterior edge of the wedge starts at the middle
portion of the labia minora, and the posterior edge is defined
by stretching the middle portion posteriorly until an ideal
shape is created. They felt that by keeping the excised
wedge far away from the clitoris would avoid putting sex-
ual sensitivity at risk.
Another group describes a technique that excises a mini-
mal amount of tissue. Choi and Kim preserve the entire outer
edge of the labia minorum and simply de-epithelialize the
central portion of the labia minorum [21]. They then re-
approximate the margins of the raw surface with a running
4.0 catgut suture. They feel this technique preserves the neu-
rovascular supply as well as the natural color, contour, and
texture of the labia minora edge.
3.2 Clitoral Hood Reduction
Clitoral hood reduction can be performed in conjunction
with labial minora reduction. Alter et al. stop the lateral inci-
sion at the lateral labium and excise the clitoral hood with a
medial ellipse extending along the edge of the clitoral hood
vertically thus excising excessive clitoral hood tissue but
preserving enough to close the skin edges [18]. In his descrip-
tion of labia minora reduction, Pardo similarly describes
trimming the clitoral hood to allow for a gentle transition
from minora to clitoral hood that avoids a step-off [12].
Fig. 2 Illustration of authors’ preferred technique. The edges of the
labia minora to be excised are marked in a symmetric fashion on both
labia. The excisions are tailored to remove more of the mucosal surface
than the external squamous epithelium thereby making the scars more
511
3.3 Hymenoplasty
In 1998, Logmans et al. described their technique of
hymenoplasty. The epithelial layer that has grown over the
ruptured hymen is removed, and the hymenal remnants are
re-approximated by a circular running suture [22]. When the
hymenal remnants are insufficient, a narrow strip of posterior
vaginal wall is dissected for reconstruction. Ou et al. also
used Logman’s approximation technique. The epithelium
and scar tissue of the hymenal remnants are removed and all
edges are approximated with 5.0 chromic catgut suture [23].
They also describe a cerclage method where a 5-0 chromic
catgut suture is introduced at the 6-o’clock position about
2–3 mm into the edge of the hymenal remnants and then run
clockwise into the submucosa to the 12-o’clock position.
The ends of the suture are tied for tightening.
4 Author-Preferred Technique
For labia minora reduction, the author performs a straight-
forward excision of the labia minora anterior edge con-
toured to the patient’s preference. The edges of the labia
minora to be excised are marked in a symmetric fashion on
both labia. The excisions are tailored to remove more of the
mucosal surface than the external squamous epithelium
thereby making the scars more inconspicuous since they
are placed on the medial (inside) surfaces of the labia. The
excessive protuberant area is excised and the remaining
edge is oversewn with a running suture. All sutures used
are absorbable (Figs. 2, 3, 4, and 5).
inconspicuous since they are placed on the medial (inside) surfaces of
the labia. The excessive protuberant area is excised and the remaining
edge is oversewn with a running suture
512 M.A. Lesavoy and C. Huang Begovic

Postoperatively patients are given antibiotics and told to

apply a significant amount of lubricant to the surgical site for
2–3 weeks. They are instructed to refrain from sexual inter-
course for 3–4 weeks. Complications include infection,
hematoma, and dehiscence. Hypertrophic scars are rare.

4.1 Dyspareunia

The author has also performed several operations for dyspa-

reunia. Often times there is a web contraction at the posterior
fornix causing pain and discomfort during intercourse and in
severe cases result in severe ulceration of the posterior for-
nix. The author has successfully released the web by per-
forming a large Z-plasty (Fig. 6). Also, the web can be
incised and a skin graft placed (Fig. 7). All of the patients
whom the author has performed these procedures on have
had significant relief of their symptoms.

Fig. 3 Photograph demonstrating the incision on the medial surface of

the labia minora

Fig. 4 Preoperative, intraoperative, and postoperative photographs of a patient with labia minora hypertrophy with asymmetric clitoral hooding
on the left
Aesthetic Surgery of the Female Genitalia 513

Fig. 5 Preoperative, intraoperative, and postoperative photographs of a patient with labia minora hypertrophy

Fig. 6 Preoperative, intraoperative, and postoperative photographs of a patient with dyspareunia repaired with a large Z-plasty
514 M.A. Lesavoy and C. Huang Begovic

Fig. 7 Preoperative, intraoperative, and postoperative photographs of a patient with dyspareunia and webbing at the posterior fornix repaired with
web incision and skin graft placement

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tion. Ann Plast Surg 40(3):287–290
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5. Lesavoy MA, Carter EJ (2006) Reconstruction of female genital
18. Alter GJ (2008) Aesthetic labia minora and clitoral hood reduction
defects: congenital. In: Mathes SJ (ed) Plastic surgery, 2nd edn.
using extended central wedge resection. Plast Reconstr Surg
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122(6):1780–1789
6. Liao LM, Creighton SM (2007) Requests for cosmetic genito-
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plasty: how should healthcare providers respond? BMJ 334(7603):
tomy with a 90-degree z-plasty for aesthetic reduction of the labia
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minora. Plast Reconstr Surg 113(6):1820–1825
7. Miklos JR, Moore RD (2008) Labiaplasty of the labia minora:
20. Munhoz AM, Filassi JR, Ricci MD, Aldrighi C, Correia LD,
patients’ indications for pursuing surgery. J Sex Med 5:1492–1495
Aldrighi JM, Ferreira MC (2006) Aesthetic labia minora reduction
8. Paarlberg KM, Weijenborg PT (2008) Request for operative reduc-
with inferior wedge resection and superior pedicle flap reconstruc-
tion of labia minora; a proposal for a practical guideline for gyne-
tion. Plast Reconstr Surg 118(5):1237–1247
cologists. J Psychosom Obstet Gynaecol 29(4):230–234
21. Choi HY, Kim KT (2000) A new method for aesthetic reduction of
9. Maas SM, Hage JJ (2000) Functional and aesthetic labia minora
labia minora (the deepithelialized reduction labiaplasty). Plast
reduction. Plast Reconstr Surg 105(4):1453–1456
Reconstr Surg 105(1):419–422
10. Alter GJ (2006) Aesthetic genital surgery. In: Mathes SJ (ed) Plastic
22. Logmans A, Verhoeff A, Raap RB, Creighton F, van Lent M (1998)
surgery, 2nd edn. Saunders Elsevier, Philadelphia, pp 389–410
Should doctors reconstruct the vaginal introitus of adolescent girls
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23. Ou MC, Lin CC, Pang CC, Ou D (2008) A cerclage method for
12. Pardo J, Sola V, Ricci P, Guilloff E (2006) Laser labioplasty of labia
hymenoplasty. Taiwan J Obstet Gynecol 47(3):355–356
minora. Int J Gynaecol Obstet 93(1):38–43
 Ancillary Nonsurgical Treatments: Trunk
and Abdomen
David S. Chang
1 Introduction
Body contouring procedures of the trunk and abdomen have
historically been among the top five surgical cosmetic proce-
dures performed in the United States [1]. These conventional
treatments for body contouring are the gold standard for
patients interested in surgically improving or correcting con-
tour abnormalities [2]. These procedures, while effective, are
associated with the standard risks of any surgical procedure
(e.g., the risks of general anesthesia, infection, wound heal-
ing complications) and the prerequisite recovery time.
Recently, there has been a trend toward minimally invasive
cosmetic procedures. While the total number of cosmetic
surgical procedures has gone down over the past 8 years, the
number of minimally invasive cosmetic procedures has
nearly doubled during that same period of time to over ten
million procedures in 2008 [1].
As physicians, it is important for plastic surgeons to criti-
cally evaluate new technology and procedures that claim to
improve appearances. The subjective nature of cosmetic pro-
cedures makes objective evaluation of results inherently dif-
ficult. How is success measured? Is it patient satisfaction,
blinded evaluation by your peers, or some other objective
measure? Despite these questions, we must strive for
evidence-based care that bases treatments on objective data
validating efficacy [3]. The randomized controlled trial is the
gold standard of evidence-based medicine, but this type of
study is difficult to conduct [4]. Most studies in plastic sur-
gery are actually case-controlled studies or case series, which
by definition are weaker. Nevertheless, there are now numer-
ous of these studies showing variable efficacy of these non-
invasive treatments to reduce torso circumference and
improve the appearance of skin laxity and cellulite [2, 5, 6].
While these studies do not meet the ideal of a randomized
D.S. Chang, MD, FACS
Private Practice, San Francisco, CA, USA
e-mail: changd@sbcglobal.net
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_36
controlled trial, they provide some evidence in favor of non-
invasive treatments to improve body contour.
In general, noninvasive treatments apply energy to the
skin surface that causes collagen denaturation and neocolla-
genesis [7]. The types of energy that is delivered can be
broadly categorized into four groups: radiofrequency
devices, optical devices, mechanical (suction, massage), and
ultrasound. The common pathway for skin tightening is via
the production of heat. In a separate category lie the inject-
ables, including mesotherapy and injection lipolysis. These
treatments are minimally invasive because they involve the
use of small caliber needles inserted into the dermis or sub-
cutaneous tissue.
The different treatments can be further categorized based
on their indications: fat reduction, skin/cellulite treatment, or
both. Cellulite is characterized by a skin surface irregularity
or dimpling that is most common in the thighs and buttocks
of women [8]. It is frequently compared to the appearance of
an orange peel or cottage cheese [6, 9]. Cellulite occurs in
90 % of postpubescent women and its exact etiology is
unknown. Factors leading to its formation are thought to
include sex hormones, genetics, and inflammation [5]. One
theory holds that cellulite is caused by herniation of fat from
the subcutaneous tissue into the dermis through dermal fas-
cial bands only present in women [10]. Regardless of the eti-
ology, its appearance is frequently disturbing to women and
getting rid of it has created a billion dollar industry [6].
Despite, or perhaps because of this, there is a general lack of
basic and clinical research into cellulite treatment [5].
The search for the least invasive procedures that prom-
ises the results of surgery without the risks and downtime
has been the holy grail of cosmetic surgery. Many treat-
ments claim to reduce fat deposits, tighten the skin, and
improve the appearance of cellulite. However, not all treat-
ments achieve these goals in all patients. While these treat-
ments may have a place in the cosmetic surgeons’
armamentarium, in general, minimally invasive treatments
for the torso result in modest improvements at best and
require several treatments over the course of weeks. They
515
516
should be reserved for the patient who cannot or will not
undergo surgery and will not tolerate any downtime or the
risks of surgery. Furthermore, patient selection and manage-
ment of patient expectations is critical to the perceived suc-
cess of these procedures.
2 Treatment Modalities
2.1 Radiofrequency
Radiofrequency (RF) devices consist of a generator that
produces an alternating current that travels from the tip of
a probe to a grounding pad placed on the patient (mono-
polar) or between two tips of a probe (bipolar). In both
types of RF devices, the radiofrequency energy is con-
verted to thermal energy by the intrinsic resistance of the
tissue to current, also known as impedance. The proposed
mechanism for the effects on skin is the effects of thermal
energy on collagen. Thermal energy results in immediate
collagen denaturation and contraction due to shortening
of collagen fibers that tightens the skin. A secondary
wound healing response results in new collagen deposi-
tion and remodeling [11]. RF energy differs from light-
based devices, such as lasers, in that it produces heat by
an electric current. It is not absorbed by melanin and does
not scatter in tissue, like lasers do. Therefore, all skin
types can be treated [12]. Some devices combine modali-
ties, including RF, optical energy (e.g., infrared), and
mechanical.
Monopolar RF devices have been mostly studied for
tightening skin in the face. In general, there are more pub-
lished studies on the use of RF for the face than for the torso.
ThermaCool (Thermage Inc, Hayward, CA, USA) is a spe-
cific monopolar device approved by the US Food and Drug
Administration for facial wrinkles [12]. The device produces
a 6-MHz current that penetrates 3–6 mm deep. The device
heats the deep dermis. A cryogen spray cools the epidermis
minimizing injury. The studies utilize slightly different pro-
tocols that make them difficult to interpret. Initial studies
used single-pass techniques, while later studies showed that
multiple passes was more effective. These studies, while lim-
ited by small numbers of patients and limited follow-up,
show that monopolar RF is safe and may make modest
improvements in ptosis and wrinkles of the face [13]. These
studies are all level 3 in grade and show a 5–20 % improve-
ment in facial skin tightening. Effects are seen after
4–12 weeks of treatments. Most authors would say that the
ideal patient is in her 30s to mid-40s and has only early signs
of aging with no actinic damage [14]. The most common
complication is mild erythema and edema that resolves
within 24 h [15]. The use of monopolar RF has been extrapo-
lated to other parts of the body based on these studies, but
D.S. Chang
there is only one published study of monopolar RF used on
the torso. Del Pino studied a monopolar RF device, Accent
RF System (Alma Lasers, Inc, Buffalo Grove, IL, USA).
This device operates at 40.68 MHz and contains two probes
that deliver energy at distances of 2–6 and 20 mm below the
skin. The purpose of the second probe is to reach the subcu-
taneous adipose. Twenty-six patients were treated on the
thighs and buttocks with 2 treatments 15 days apart. Patients
were evaluated by ultrasound scanning of the subcutaneous
tissue 15 days after the last treatment. Sixty-eight percent of
patients had a 20 % reduction in volume of subcutaneous fat.
They report changes are still present at 6 months. They do
not report on any objective evaluation of cellulite
appearance.
In bipolar RF, the current passes between two electrodes.
The depth of penetration depends on the distance between
electrodes, but the overall penetration is less than with mono-
polar RF. Energy does not reach the deep dermis or subcuta-
neous tissues. Montesi studied the effects of a bipolar device,
the Aluma device (Lumenis Inc, Santa Clara, CA, USA) on
30 patients, but only four patients were treated for abdominal
striae and three for gluteal-trochanteric contouring [16]. In
these small number of selected patients, there was a >50 %
improvement in appearance in most patients, with visible
tightening of skin. Skin biopsies showed increased type 1
collagen after treatment. The duration of the results is not
known. Because of the small number of patients, it is diffi-
cult to make any conclusions on the efficacy of bipolar RF on
body contouring.
A third type of RF device utilizes three electrodes, com-
bining the effects of monopolar and bipolar RF. The Regen
(Pollogen Ltd, Tel Aviv, Israel) operates at 1 MHz and gener-
ates 20–28.5 W, which is between bipolar and unipolar
RF. Manuskiatti looked at the effects of tripolar RF in 39
women [17]. Patients were treated once a week for 8 weeks.
Treatments last almost 3 h to treat the abdomen, arms, but-
tocks, and thighs. There was a significant reduction in cir-
cumference of the thigh (1.7 cm) and abdominal
circumference (3.5 cm), but not the buttock or arms.
Ultrasound (US) measurements of subcutaneous adipose
showed <1 mm of change. Blinded physician raters found on
average 50 % improvement. The authors found that less skin
laxity and cellulite present pretreatment, the better the
response.
One of the newest RF device aimed specifically at treating
cellulite is the ThermaLipo (Thermamedic Ltd, Alicante,
Spain) [18]. It is a bipolar RF device that automatically
changes frequencies based on tissue impedance. In a study of
50 patients treated weekly for 12 weeks, two-thirds were
rated by blinded physicians as being very good or good. Skin
texture was measured using three-dimensional optical imag-
ing. At 2 months, there was a 42–50 % improvement in skin
texture. Patient satisfaction was 76 %.
Ancillary Nonsurgical Treatments: Trunk and Abdomen
2.2 Optical Devices
Lasers are the gold standard for ablative resurfacing of the
skin, particularly in the face. Optical devices consisting of
lasers and light sources, alone or in combination with other
modalities such as RF, have recently been used for body con-
touring of the torso. Specifically, these devices target the
treatment of cellulite. Optical devices alone have been evalu-
ated with variable success. Intense pulsed light (IPL) therapy
utilizes light in the visible spectrum and is approved by the
United States Food and Drug Administration (FDA) for
treating cutaneous lesions and removing hair [19]. It is
thought to increase collagen thickness in the dermis [20]. In
one small study looking at IPL [Quadra Q4 IPL system
(DermaMed, Lenni, PA, USA)] combined with a retinyl
cream, Fink reported a 50 % improvement in cellulite appear-
ance. There was no control group, and 25 % of the patients
dropped out of the study [19] making the results difficult to
interpret. In another study, Bousquet-Rouaud investigated
the Nd:YAG laser (1,064 nm) to treat cellulite with the oppo-
site thigh as a control. In 11 patients, the results showed
slight improvement. Patients were also evaluated by ultra-
sound which showed a thinning of the dermis [9].
Other devices that utilize optical energy include Synergie
Aesthetic Massage System (Dynatronics, Salt Lake City, UT,
USA) which combines massage with 660–880-nm light
source; Triactive (Cynosure, Westford, MA, USA) which
utilizes 810-nm diodes laser with suction massage;
SmoothShapes 100 (SmoothShapes, Merrimack, NH, USA),
which combines a 915-nm laser and a 650-nm light source;
and Velasmooth (Syneron Medical Ltd, Yokneam, Israel)
infrared light (700–2,000 nm), bipolar RF, suction, and
mechanical massage. Of these devices, Triactive has been
shown to produce a 21 % improvement in cellulite [6].
Velasmooth has been most extensively studied and will be
discussed in more detail below in the section on combined
modality devices.
2.3 Mechanical Massage
Endermologie was developed in the 1970s by a French engi-
neer as a way of doing the manual work of physical therapy
he was receiving to soften scars he had developed after an
automobile accident. The unintended effect of this device
was its improvement on cellulite. Endermologie has been
used throughout the world to treat cellulite for years before it
was introduced in the United States in 1996 for the treatment
of cellulite. Although thousands of devices have been sold,
its efficacy is considered controversial [21–23]. The device
produces a positive pressure through rollers and a negative
suction. It is thought to increase lymphatic flow and stretch
the vertical connective tissue. Furthermore, it is thought to
517
create a sublethal injury to fat cells, which then remodel dur-
ing healing to reduce the appearance of cellulite.
In 1997, the then American Society of Plastic and
Reconstructive Surgeons published a review of Endermologie
and concluded that its claims had not been substantiated by
appropriate scientific investigations [24]. Since then, there
have been more studies on Endermologie [23], but none has
definitively shown it to be effective at either fat reduction or
cellulite reduction. The largest of these studies enrolled 85
patients treated for 7 or 14 weeks [22]. After 14 treatments,
the average loss in circumference was 1.83 cm. There were
widely variable results, but 90 % of patients reported a favor-
able improvement in cellulite. In a contrast, a rare random-
ized controlled study of Endermologie with or without
aminophylline cream had overall poor results [25]. Of the
patients randomized to Endermologie, only 11 % showed
improvement on clinical exam and less than one-third of
patients thought that there was improvement. Gulec treated
33 patients with Endermologie and showed that there was a
significant reduction in circumference in all body areas
treated (arms, breasts, waist, hips, subgluteal region, thigh,
knee, and calf) [26]. Total body circumference was lower
whether patients gained or lost weight. However, only 15 %
of patients showed an improvement in cellulite appearance.
Adverse effects reported in this study were pain and ecchy-
mosis, which were self-limiting.
While it appears that Endermologie can reduce body cir-
cumference measurements after numerous treatments, these
results are modest at best (1–2 cm). It is not clear that this
reduction is greater than what can be achieved through diet
modifications and exercise as weight loss is closely corre-
lated with body circumference [22]. Furthermore, without an
objective way to measure cellulite, any reported improve-
ments must be considered anecdotal.
2.4 Ultrasound
Transdermal focused ultrasound (FUS) has been studied as
a means of reducing subcutaneous adipose with variable
success. Unlike other surface treatments that primarily
tighten the skin, FUS targets the subcutaneous tissues by
mechanically disrupting adipocytes [27]. It is theorized that
the body metabolizes the fat, but what exactly happens to it
is unknown. Several studies have found that FUS is safe
and can reduce body circumference and subcutaneous adi-
pose thickness with results lasting at least 3 months [27].
Average reduction in fat thickness was 2.3 cm, and body
circumference was reduced by almost 4 cm with the
Contour I device (UltraShape Ltd, Tel Aviv, Israel) after
three treatments. In a larger study of 137 patients across
multiple countries (United States, England, Japan),
Teitelbaum studied the effects of a single FUS treatment,
518
also using the Contour 1. The reductions were more mod-
est, 2 cm in circumference, and 2.9 mm in fat thickness
[28]. Adverse effects were mild: erythema, purpura, blis-
ters, and one skin ulceration that healed. No changes were
noted in serum lipids or liver ultrasound after one treat-
ment. Three treatments, however, resulted in a significant
elevation in triglyceride levels that remained within normal
levels [27]. Both studies conclude that the procedure should
be reserved for patients with localized fat deposits who
desire small or moderate reductions.
Contrasting these positive results is a study that looked at
the same FUS device in Asian patients [29]. In 53 patients,
the authors found no significant difference in abdominal cir-
cumference, US-measured subcutaneous fat thickness, or
caliper-measured fat thickness after 3 treatments. Overall
satisfaction was poor. The authors explained the difference
by stating that the body frame of Asians is smaller with more
bony prominences and less voluminous adipocytes. This
explanation is curious given the results of the Teitelbaum
study also included Asian patients from Japan. These contra-
dictory findings of focused US suggest that more studies
need to be conducted before any firm conclusions can be
made.
2.5 Combination Therapies
Radiofrequency combined with optical and mechanical
energy has also been studied for noninvasive body contour-
ing with variable success. The VelaSmooth and VelaShape
(Syneron Inc, Irvine, CA, USA) combine bipolar RF with
infrared (IR) energy and mechanical suction-based massage.
Both devices are currently FDA approved for the “relief of
minor aches and pain, relief of muscle spasm, temporary
improvement of local blood circulation, temporary reduction
in the appearance of cellulite, and for temporary reduction of
thigh circumferences” [30]. The RF energy targets the deeper
subcutaneous tissue, while IR light penetrates 1–3 mm into
the dermal-fat junction. The combined heat of these two
energies creates a controlled inflammatory response [8] and
is thought to increase oxygen release for fat metabolism [31].
The mechanical component improves circulation and possi-
bly stretches the connective tissue in the subcutaneous fat,
providing as theoretic benefit similar to that of Endermologie
[8]. The treatments have been shown to be safe with minimal
adverse effects including, mild erythema, pain, edema, and
bruising [8, 32, 33]. However, evaluating the efficacy of the
several small studies using this device is difficult. Different
investigators use slightly different treatment protocols with
highly variable results. The number of treatments varies
between 5 and 12 times over a period of weeks to months [8,
31–37]. These studies show that there can be a 25–50 %
improvement in appearance of cellulite [8, 31, 32, 36].
D.S. Chang
Reduction in circumferences is also variable, from no change
to greater than 2 cm [32, 34]. Winter showed an overall
5.4 cm reduction in circumference, but his study lacked a
control group and clinical evaluation of cellulite was not
blinded [34]. In some instances, the results last 6 months [8],
while in others, the results were gone at 8 weeks posttreat-
ment [32, 33]. Furthermore histological specimens after
treatment have shown no changes. [31, 32]. While the tech-
nology may have some merit, at best it is a temporary. Given
the highly variable results, it should be approached cau-
tiously. It would be difficult to deal with the unhappy patient
who was one of those who had no result from months of
treatment. Further studies are clearly necessary to objec-
tively characterize results and compare treated patients to
proper control groups.
2.6 Injectables (Mesotherapy and Lipolysis)
Mesotherapy refers to the intracutaneous or subcutaneous
injection of minute quantities of pharmacologic agents pro-
posed to treat a variety of medical conditions [38]. The tech-
nique has been around for thousands of years, but modern-day
mesotherapy is credited to the French physician, Michael
Pistor, in 1952 [39]. Originally, it was used to treat sports
injuries, chronic pain, and rheumatologic disorders [40]. The
French Society of Mesotherapy was founded in 1964 [39],
and in 1987, the French National Academy of Medicine
acknowledged mesotherapy as an official specialty of medi-
cine [38]. To this day, it is still mostly used for noncosmetic
purposes in Europe. It has been used to treat a wide range of
conditions from acne to vertigo. Depending on the condition
being treated, the technique involves injections of a cocktail
containing plant extracts, medications, vitamins, and/or
other drugs [38, 41]. The exact ingredients and quantities
injected are highly variable and based entirely on experience,
rather than empiric data [38].
Mesotherapy has recently gained popularity in the United
States as a cosmetic treatment [39]. Specifically, it is has
been marketed a treatment for cellulite and wrinkle reduc-
tion. Treatments frequently involve numerous injections
given at multiple sessions with a 27 or 30G needle. The
injection techniques vary from injector to injector, and the
drugs injected have not been standardized. Furthermore,
there is a paucity of scientific or clinical data backing up any
claims of efficacy. A recent study from South Korea found
no statistically significant changes in thigh girth or CT scan
measurements of cross-sectional area in patients treated with
mesotherapy containing aminophylline, buflomedil, and
lidocaine [42]. For these reasons, in the United States, the
FDA has not approved the use of any medication for use in
mesotherapy. The mechanism of mesotherapy is also
unknown. Some of the components used in mesotherapy
Ancillary Nonsurgical Treatments: Trunk and Abdomen
have been shown to cause beta-adrenergic activation and
alpha-2 inhibition. It is theorized that this may induce lipoly-
sis [39]. While there is some theoretic basis for the effects of
mesotherapy, to this day, there are no peer-reviewed clinical
trials validating the beneficial effect of mesotherapy on cos-
metic conditions. Because of the lack of data, both the
American Society of Plastic Surgeons and the American
Society for Aesthetic Plastic Surgery have issued warnings
against the use of mesotherapy until further investigation has
been completed [1, 43].
Injection lipolysis or lipodissolve is a slightly different
procedure that is often equated with mesotherapy. It is
intended specifically to reduce small, localized deposits of
adipose. Proponents of injection lipolysis will argue that
unlike mesotherapy, the injection formula and technique for
injection lipolysis has been standardized [44]. Injection
lipolysis involves the injection of 2.5–5.0 % phosphatidyl-
choline and 4.2–4.7 % sodium deoxycholate into the subcu-
taneous fat [38]. The first published report describing the use
of this preparation for localized fat reduction was by the
Brazilian dermatologist Patricia Rittes in 2001 [45]. She
found a significant reduction in prominent lower eyelid fat
pads in 30 patients. Since her report, there have been several
others reporting successful reduction of fat deposits with
injection lipolysis [44, 46–49].
There are thought to be two active ingredients in the lipo-
dissolve preparation: phosphatidylcholine and sodium
deoxycholate. Phosphatidylcholine is a normal component
of the cell membrane. It is involved in several vital body
functions, including digestion of dietary fat and cholesterol
metabolism. It is also a component of alveolar surfactant and
helps to maintain cell membrane integrity. It is sold as an oral
dietary supplement, and in Europe, intravenous phosphati-
dylcholine is marketed as Lipostabil (Artesan Pharma,
Luchow, Germany). It is used to treat hyperlipidemia, ath-
erosclerosis, angina, hypertension, and prevention of fat
embolism. In the United States, it is not FDA approved for
injection, but can be purchased through compounding phar-
macies, the Internet, or in Europe [39]. The exact mechanism
of how injected phosphatidylcholine reduces fat deposits is
not known. It is theorized that it helps emulsify fat cells
through lysis of cell membranes. In vitro, it has been shown
to cause lysis of adipocytes [50, 51]. In both animal models
and humans, it also produces necrosis of fat and an inflam-
matory response [44, 52–54]. Deoxycholate is a bile salt that
is used to solubilize phosphatidylcholine. It was initially
thought that the active ingredient in lipodissolve was phos-
phatidylcholine. However, recent studies suggest that deoxy-
cholate is equally effective at causing cell lysis as
phosphatidylcholine [50, 55, 56]. Furthermore, it is likely
that the lysis effect is not specific to adipocytes [51, 54].
Most studies on lipodissolve are merely anecdotal
cases or case series [44–47]. More recent studies have
519
attempted to elucidate the active ingredient for injection
lipolysis by randomizing patients to phosphatidylcholine
+ sodium deoxycholate or sodium deoxycholate alone
[55, 56]. These are randomized, double-blind studies
showing that both formulations can reduce subcutaneous
fat deposits in the gluteal-trochanteric areas [56] and sub-
mental area [55] equally as effectively. In the first study,
40 patients received an injection of phosphatidylcholine +
sodium deoxycholate in one thigh and sodium deoxycho-
late alone in the opposite thigh. Three patients had no
response. In the remainder, the mean circumferences were
reduced by 6.46 % and 6.77 %, respectively. Ultrasound
measurements of subcutaneous fat were reduced by
36.87 % and 36.06 %, respectively [56]. In the second
study, 28 patients were injected with either phosphatidyl-
choline + sodium deoxycholate or sodium deoxycholate
alone [5]. Blinded clinicians rated photographs by assign-
ing the temporal sequence to the photographs and grading
improvement in fat deposits. Sixty-five percent and sev-
enty-five percent of the photos were assigned correctly for
the phosphatidylcholine + sodium deoxycholate and
sodium deoxycholate groups. There was a modest overall
difference.
The most common adverse reactions are localized pain,
pruritus, erythema, edema, nodules, and hematoma [39, 55,
56]. These often resolve over the course of days [47], but can
last up to 2 weeks [55]. Systemic reactions of loose stools
and menstrual bleeding outside the normal cycle are rare, but
have been reported [47]. Anaphylaxis has not been reported
[39]. Most studies have reported no change or improvement
in lipid profiles [44]; however, in a case report, one patient
had significant elevations in serum triglycerides and free
fatty acids [54] 4 months after treatment. There have been
reported cases of tissue loss associated with skin ulceration
that has been attributed to poor judgment and excess com-
pression [57].
These studies are all suggestive of beneficial effect of a
potential beneficial effect of injection lipolysis; there is still
much unknown with regard to the mechanism of injection
lipolysis. What happens to dissolved fat is not known. In
2008, The American Society of Plastic Surgeons issued a
statement cautioning its members on the use of mesother-
apy and injection lipolysis. How can authors simultane-
ously state that “limited scientific data are available on
injection lipolysis” and that there is a “plethora of data on
the subject?” The truth is that the “plethora” of data is of
limited scientific rigor. While there may be some validity to
the statement that the technique of injection lipolysis is safe
and efficacious, presently there are not enough well-
designed studies supporting the use of injection lipolysis as
a reliable method. In the United States, as of 2010, the FDA
has not approved any drugs for the indication of dissolving
fat [58].
520
Conclusions
When it comes to ancillary treatments for the torso, there
exists the greatest area for both innovation and quackery.
Patients are hungry for the newest and greatest treatments
that promise to restore the look of youth without the pain
and downtime of surgery. As physicians, plastic surgeons
also have an obligation to practice evidence-based medi-
cine, even in the pursuit of aesthetic improvement.
Treatments must be supported by evidence, not intuition
or anecdotal unsystematic clinical experience. The pres-
ent literature on ancillary treatments for the torso is weak.
There is a general lack of compelling scientific data to
support all of the claims made. The studies lack proper
control groups and are often inherently biased by relying
on patient-generated satisfaction data to support their
results. These studies should not be discounted com-
pletely. They raise the question of better-designed studies
with appropriate controls. Those who use these tech-
niques must make honest assessments of the goals of
treatment and discuss realistic expectations with patients
in light of the studies. As with any procedure or operation,
patient selection is paramount to predicting results.
Unfortunately, the great variability in treatment protocols
from number of treatments, energy delivered, endpoints
of treatment, etc., makes it more difficult to get predict-
able results.
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 Part IV
The Scalp
 General Concepts and Indications
Marco Toscani and Mariangela Ciotti
1 Introduction
Baldness can occur as a consequence of several causes.
Temporary or permanent, cicatricial or not, a sign of a
metabolic dysfunction or other disorders, alopecia requires,
more than any other disease, a correct etiopathogenic
understanding, both of its psychological impact and to avoid
worsening due to an inadequate treatment.
The selection of “surgical” patients is therefore an impor-
tant step for the correct treatment of alopecia. Cases of
androgenic or cicatricial alopecia are commonly considered
of surgical pertinence, except for very young patients and
those affected by alopecia areata, dysmetabolic disorders,
autoimmune diseases, or oligoelement deficiency.
Among the multiple possible causes of alopecia, andro-
genic alopecia (AGA) is undoubtedly the most common, in
both men and women. In the past, AGA was defined as a
paraphysiologic status of the male patient. Nowadays, exten-
sive research suggests it is a chronic pathologic condition,
genetically determined, characterized by a progressive invo-
lution of the hair follicles related to androgen hormones, with
miniaturization and progressive hair loss, also affecting
women. Hair loss in certain body areas (forehead, temples,
vertex) that is progressive with age can lead to important psy-
chological consequences. Many patients consult clinicians,
dermatologists, and surgeons in the hope that they can retrieve
the lost hair, but their expectations are often unrealistic.
Baldness surgery does not stop the evolution of AGA (just
as it is not possible to interrupt the aging process). The aim
is to correct, at least in part, the consequences of the hair
loss: its general principles are to reduce the hairless areas
and obtain an aesthetic redistribution of the remaining hair. It
M. Toscani, MD (*)
Dipartimento di Chirurgia,
Università di Roma “Sapienza”, Rome, Italy
e-mail: marcotoscani@libero.it
M. Ciotti, MD
U.O.C. di Chirurgia Plastica,
Università di Roma “Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_37
is possible to associate a medical therapy with the aim of
stopping or, at least, reducing non-transplanted hair loss.
It is important to specify that medical therapy is effective
only during the period of drug consumption and that the ben-
efits are lost when this is suspended. However, baldness is an
evolutionary process, and patients must be thus informed.
2 Physiology
Hairs are elongated keratinized structures arising from an
indentation on the epidermis, the hair follicle. The producing
part is the hair bulb, located at the base of the follicle, seated
on a highly vascularized dermal papilla.
The speed of hair growth is about 1–1.5 cm per month.
Hair is an living element that follows a specific growth cycle
(lasting from 2 to 6 years) characterized by a growing stage
called anagen, a transitional stage, the catagen, and a resting
stage called telogen. In humans, unlike the other mammals
that undergo periodic molting, this cyclic evolution is not
synchronous so that each hair is independent from the others
[1]. Physiologic hair loss of up to 100 hairs per day is consid-
ered normal.
The hair follicle is under hormonal control: the action of
the androgens (gonadal or adrenal) is amplified by an enzyme,
5α-reductase, that converts testosterone into dihydrotestos-
terone. The action of this hormone determines, by interacting
with androgen receptors on the hair bulbs of certain body
areas (forehead, crown, vertex) in genetically predisposed
subjects, progressive miniaturization and premature hair loss.
3 Androgenic Alopecia
3.1 In Men
AGA can occur as early as the end of adolescence with
alternate evolutionary phases, often in families with a posi-
tive medical history of baldness. It begins with a receding
525
526 M. Toscani and M. Ciotti

Fig. 1 Hamilton
classification: classification
into seven types to which it is
possible to add an index
according to the anterior (a) or
vertex (v) extension, thus
identifying five subtypes

hairline above the temples and vertex of the scalp. Rapidly
evolving cases in very young subjects often progress to com-
plete baldness, referred to as a “Hippocratic wreath.” The
forms that begin after 30 years of age usually have a slower
evolution.
A standardized description of male pattern alopecia
distribution was introduced in 1941 by Hamilton [2] (Fig. 1),
who classified the most common types in seven main stages.
This classification was then modified in 1975 by Norwood
and Shiell [3] with the addition of four variants.
General Concepts and Indications 527

Fig. 2 Female alopecia. Ludwig classification in three stages

3.2 In Women

AGA is less common in women than in men. It differs from

male alopecia in the following ways:

• Retention of a 1-cm hair-bearing frontline

• Diffuse hair thinning involving the temples, vertex, and
sometimes also the occipital region

In some cases its aspect can follow the male pattern. In

women it is possible to prescribe hormonal antiandrogen
treatments to interrupt the evolution. Female AGA is gener-
ally classified on the Ludwig scale [4], which divides this
disease into three stages according to the hair density
(Fig. 2).

4 History of Baldness Surgery

Baldness surgery is a recent subject. Until the end of the

1950s it was almost non-existent, although some authors had
already described techniques for reducing the alopecic area
[5, 6], flaps (Passot in 1920 described an inferior pedicle flap
model (Fig. 3), precursor of the Juri flap and the first superior
pedicle flap model), and scalp grafts [7].
A decisive turn came in 1959 after the publication of
Orentreich’s studies, which determined the beginning of
modern hair transplantation [8]. Orentreich described his
observation that scalp grafts harvested from the posterior and
lateral region of the head, if transplanted to the frontal
alopecic area, produced normally growing hair that kept the
characteristics of the donor area. He thus assumed that those
bulbs were insensible to hormonal influences.
In 1975, Juri published a large axial pedicle flap model
allowing extensive coverage of the frontal region but with an
unnatural hair direction [9] (Fig. 4).
Fig. 3 Passot flap
Finally, Nataf [10, 11], resuming Passot’s ideas, described
in 1976 a random vascularized superior pedicle flap,
preserving the natural hair direction (Fig. 5).
The problem of hair direction led Ohmori to propose in
1980 the microsurgical transfer of a flap derived from Juri on
the contralateral temporal pedicle [12] (Fig. 6).
Over the last 15 years, the evolution of the techniques has
been undeniable. Brandy realized consecutive wide reducing
procedures of bald areas [13]. Marzola added to these
reductions an anterior marginal superior pedicle flap per-
528
formed in two steps, which was then refined by Dardour with
the concept of “scalp lifting” [14–16] (Fig. 7).
Since the 1980s the use of tissue expansion techniques in
the treatment of baldness has been developed by several
authors worldwide (as later reported by M. Unger).
Large cylindrical grafts performed during transplantation
procedures leading to an unnatural “doll’s-head” like effect
Fig. 4 The Juri temporo-parieto-occipital flap. The flap is based on the
posterior branch of the temporal artery, and is 25 cm long and 3.5 cm
wide. It requires a two-step preparation. It is possible to perform (sec-
Fig. 5 Evolution of the superior pedicle flaps (modifications by Nataf and Bouhanna)
M. Toscani and M. Ciotti
were progressively abandoned in the 1990s in favor of mini
and micro grafts composed of one to four hairs (follicular
units (FU)) which, if implanted at the correct angle, can lead
to a definitively better result [17, 18].
In 1992, Fréchet proposed a technique of scalp extension,
patenting an apposite elastomer [19, 20].
ondly) the same flap surgery on the opposite side. Its main aesthetic
defects are the unnatural hair direction and the design of the arch on the
pedicle side
General Concepts and Indications 529

Fig. 6 Free Ohmori temporo-parieto-occipital

flap. This is a Juri flap based on a temporal artery
that is microanastomosed onto the contralateral
temporal artery. This expedient allows
procurement of a natural hair direction

a b

Fig. 7 (a) Preauricular Dardour flap. (b) Retroauricular Dardour flap

530
5 Surgical Anatomy of the Scalp
The scalp consists of five layers: skin, subcutaneous tissue,
galea, loose areolar tissue, and pericranium.
The skin of the scalp is the thickest skin of the body, rang-
ing from 8 mm in the occipital region to 3 mm in the anterior
and temporal regions.
The subcutaneous tissue contains arterial and venous ves-
sels, lymphatic vessels, and sensitive nerves. It consists of
adipose tissue and fibrous connective tissue organized in
fibrous septa that make this layer inelastic and firm.
The aponeurotic galea is part of the subcutaneous
musculo-aponeurotic system of the face. It has a quadrilat-
eral shape, and therefore has a superficial and a deep face
and four margins, anterior, posterior and two laterals.
The superficial face is firmly connected to the overlying
structures through the septa that pass across the subcutane-
ous layer.
The deep face is separated from the pericranium by a deep
layer of avascular connective tissue. It is connected anteri-
orly with the frontalis muscle, posteriorly with the occipitalis
muscle, and laterally with the temporoparietal fascia and
anterosuperior auricular muscles.
The frontalis muscle is flat and has a quadrilateral shape.
It originates from the anterior margin of the galea and runs
anteriorly and downward until the deep face of the skin in
correspondence with the eyebrows, glabella, and superior
portion of the dorsum of nose, where it inserts. It interdigi-
tates with fibers from the procerus, corrugator supercilii, and
orbicularis oculi muscles. The frontalis muscle, by contract-
ing, moves the scalp forward and causes frowning.
The occipitalis muscle has a laminar shape and originates
from the posterior margin of the epicranial aponeurosis. Its
fibers run obliquely, medially, and downward to insert on the
posterior nuchal line and the mastoid process.
The occipitalis muscle, by contracting, moves the scalp
backward.
The anterosuperior auricular muscle is located in the tem-
poral region, forward and superiorly to the auricula. It origi-
nates from the lateral margin of the galea and inserts on the
lateral face of the auricula in correspondence with the helix,
the spine of the helix, and the anterosuperior part of the con-
vexity of the concha. It consists of two portions, anterior and
posterior, between which runs the parietal branch of the ante-
rior superficial temporal artery.
The frontalis, occipitalis, and anterosuperior auricular
muscles are intrinsic muscles and belong to the group of
mimic muscles.
The loose areolar tissue, or subaponeurotic layer or sub-
galeal fascia, consists of thin avascular connective tissue.
Caudally, it continues deeply with respect to the temporo-
parietal fascia until the cheeks, where it represents the parot-
ideomasseteric fascia.
M. Toscani and M. Ciotti
This space is traversed by emissary veins that run from
the subcutaneous layer of the scalp to the intracranial venous
sinuses. The laxity of this layer explains the mobility of the
scalp.
This space is considered the “danger zone” of the scalp
because hematoma or infection can easily spread through it,
and thrombosis of the emissary veins may extend to the dural
sinuses.
The innermost layer of the scalp, the pericranium, is
firmly connected to the outer table of the skull. At the
level of the superior temporal line, the pericranium fuses
with the deep temporal fascia. The deep temporal fascia
consists of a superficial layer that adheres to the lateral
border of the zygomatic arch, and a deep layer that adheres
to the medial border of the zygomatic arch. The superfi-
cial temporal adipose tissue is located between the two
layers.
6 Vascularization (Fig. 8)
6.1 Arteries
The scalp is highly vascularized by four main arteries and
smaller vessels. The main arteries are the occipital and super-
ficial temporal arteries on each side. The smaller vessels of
the scalp are the posterior auricular artery, small branches of
the posterior auricular artery, small branches of the external
carotid artery, and supraorbital and supratrochlear vessels.
These vessels are contained in the subcutaneous layer and
form numerous anastomoses to allow the survival of the
entire scalp on a major vessel in the case of avulsion.
6.2 Occipital Artery
The occipital artery arises from the external carotid artery
above the origin of the lingual artery and runs posteriorly,
upward, and outward, passing beneath the posterior belly of
the digastric muscle and then in the groove of the mastoid
process. It pierces the fascia connecting the cranial attach-
ment of the trapezius and sternocleidomastoid muscles, and
ascends to the epicranial aponeurosis. Along its course it
divides into the following branches:
• Muscular branches for the sternocleidomastoid, digastric,
stylohyoid, splenius, and longissimus capitis muscles
• Mastoid branch, which enters the skull through the mas-
toid foramen and supplies the mastoid cells and the dura
mater
• Auricular branch, which supplies the back of the concha
• Descending branch, which runs down between the mus-
cles of the back of the neck, and divides into superficial
General Concepts and Indications 531

Middle temporal Parietal emissary vein

artery and vein Branches of
Frontal
superficial temporal
Parietal
artery and vein
Zygomatico-orbital
artery

Facial transverse Inferior auricular

artery and vein arteries

Supraorbital vein

Supratrochlear
artery and vein

Zygomatico-
temporal artery
Mastoid emissary vein and
and vein
meningeal branch of occipital artery
Angular artery
and vein Occipital artery and vein

Posterior auricular artery and vein

Zygomatico-facial External jugular vein (section)

artery and vein Posterior facial (or
retromandibular) vein
Deep facial vein Internal jugular vein
(of pterygoid plexus) Internal carotid artery
External carotid artery
Common carotid artery
External maxillary (or facial)
artery and anterior facial vein Lingual vein

Occipital nerve

Posterior auricular nerve

Fig. 8 Vascularization and innervation of the scalp

532
and deep portions. The superficial portion anastomoses
with the transverse cervical artery. The deep portion
anastomoses with the vertebral and deep cervical arteries
• Meningeal branches, which enter the skull through the
jugular foramen and condyloid canal, to supply the dura
mater in the posterior fossa
The terminal branches of the occipital artery are the
occipital branches, which spread through the posterior region
of the head and supply the occipital muscle and skin. These
branches, with a tortuous course, anastomose to the contra-
lateral occipital branches and the branches of the superficial
temporal artery.
6.3 Posterior Auricular Artery
The posterior auricular artery arises above the posterior belly
of the digastric muscle, and ascends in the groove between
the auricle and the mastoid process.
The stylomastoid artery is a collateral branch of the pos-
terior auricular artery. It enters the facial canal through the
stylomastoid foramen and supplies the mastoid cells, the sta-
pedius muscle, and the tympanic cavity.
Its terminal branches are the auricular branch, which sup-
plies the two surfaces of the auricle, and the occipital branch,
which supplies the occipital muscle and the skin of the sur-
rounding area.
6.4 Superficial Temporal Artery
The superficial temporal artery is the most important vessel
of the scalp because of its length and surface supply. It begins
in the substance of the parotid gland, behind the neck of the
mandible, and ascends in front of the tragus. In the temporal
region, beneath the skin, it divides into a frontal and a pari-
etal branch. When it passes anterior to the tragus it is only
covered by the skin, and its pulse is palpable (pulsatility). It
is accompanied by the corresponding vein and the auriculo-
temporal nerve.
Its collateral branches are:
• Parotid branches for the parotid gland
• Transverse facial artery
• Anterior auricular branches for the auricula and the exter-
nal meatus
• Zygomatico-orbital branch, which runs along the upper
border of the zygomatic arch, to the lateral angle of the
orbit
The middle temporal artery perforates the temporal fascia
and supplies the temporal muscle
M. Toscani and M. Ciotti
Its terminal branches are:
• Frontal (anterior) branch, which supplies the frontal region
• Parietal (posterior) branch, which supplies the skin and
the epicranial aponeurosis of the parietal region
6.5 Supratrochlear and Supraorbital
Arteries
The supratrochlear and supraorbital arteries supply the ante-
rior region of the scalp. They both arise from the ophthalmic
artery. The supraorbital artery passes between the superior
rectus muscle and levator palpebrae superioris muscle, to the
apex of the orbit. Together with the supraorbital nerve it
passes in the supraorbital groove and exits the orbit to supply
the skin, the muscles, and the bones of the frontal region.
The supratrochlear artery is one of the terminal branches
of the ophthalmic artery. It exits the orbit through the supe-
rior medial angle and ascends to the forehead, supplying the
skin and the epicranial muscles.
The supratrochlear and supraorbital arteries anastomose
in the frontoparietal subcutaneous layer of the scalp. This
anastomotic network gives off numerous perforating vessels
through the pericranium to the external cortical bone.
6.6 Veins
The venous blood from the scalp is drained by the jugular
vein. The extracranial venous circulation is connected to the
intracranial venous circulation through several emissary
veins. The emissary veins, after passing through the cranial
theca, connect to the dural sinuses. The venous system of the
scalp follows the arterial one.
The frontal, supraorbital, and nasofrontal veins unite
superficially at the medial angle region of the eye to form the
angular vein, which runs obliquely downward and backward
with a linear course, receiving numerous branches to become
the anterior facial vein. The area of the anterior facial vein
corresponds to that of the external maxillary artery.
The union of the superficial temporal vein and the middle
temporal vein, anterior to the auricle, forms the posterior
facial vein. Its area corresponds to that of the superficial tem-
poral artery.
It descends in the substance of the parotid gland, behind the
ramus of the mandible and lateral to the external carotid artery.
At the angle of the mandible it anastomoses to the external
jugular vein and then unites with the anterior facial vein.
The superficial temporal vein originates from the subcuta-
neous venous network of the cranial vault, and anastomoses
to the contralateral homonym vein and to the frontal, supra-
orbital, posterior auricular, and occipital veins.
General Concepts and Indications 533

7 Innervation (Fig. 9)
The scalp has numerous sensitive nerves. The supraorbital
and supratrochlear nerves, terminal branches of the ophthal-
mic division of the fifth cranial nerve, innervate the anterior
region of the scalp and the forehead. The frontal nerve, the
largest terminal branch of the ophthalmic nerve, enters the
orbital cavity through the superior orbital fissure, external to
the tendinous ring (annulus of Zinn). It runs along the apex
of the orbital cavity in close contact with the periosteum,

From the ophthalmic

division of trigeminal
nerve (V1)
Supraorbital nerve
Supratrochlear nerve Auricular branch
of vagus nerve (X)
Palpebral branch
of lacrimal nerve
Infratrochlear nerve
External nasal branch
of anterior ethmoidal nerve

From the maxillary Medial branches

division of trigeminal of posterior divisions
nerve (V2) of cervical spinal nerves
Zygomaticofacial nerve Greater occipital nerve (C2)
Zygomaticotemporal Third occipital nerve (C3)
nerve Spinal nerves C4, C5, C6, C7
Infraorbital nerve and C8

From the mandibular Branches of cervical plexus

division of trigeminal Lesser occipital
nerve (V3) nerve (C2,C3)
Mental nerve Great auricular
Buccal nerve nerve (C2, C3)
Transverse cervical (or
Auriculo-temporal nerve cutaneous cervical) nerve
(C2, C3)

Posterior divisions
of cervical spinal nerves

Ophtalmic nerve (V1)

Auricular branch of vagus
nerve to the external acoustic
Trigeminal meatus and small area of
Maxillary nerve (V2) postero-medial
nerve (V)
aspect of the auricula

Mandibular nerve (V3)

Branches of cervical plexus

Fig. 9 Innervation of the scalp

534
superior to the levator palpebrae superioris. Along its course
on the orbital margin it divides into the supratrochlear, fron-
tal, and supraorbital branches.
The supratrochlear branch is the smallest and most medial
of these three nerves. It exits from the orbital cavity above
the pulley of the superior oblique muscle, and supplies the
upper eyelid, the nasal root, and the skin of the glabella.
The frontal branch, which is intermediate and outside the
orbit, surrounds the orbital margin of the frontal bone and
ascends to supply the skin of the frontal region.
The supraorbital branch is the largest and most lateral of
the branches of the frontal nerve. It passes through the supra-
orbital foramen of the frontal bone along with the supraor-
bital artery. Along its course it gives off numerous ascending
branches that extend to the scalp. In addition to the cutane-
ous branches for the forehead and the scalp, the supraorbital
nerve supplies the skin and the conjunctiva of the middle
upper eyelid.
The occipital region of the scalp is innervated by the dor-
sal ramus of cervical spinal nerves 2 and 3.
The dorsal ramus of cervical spinal nerve 2, or greater
occipital nerve, is the largest posterior branch of the spinal
nerves. It arises from between the first and second cervical
vertebrae, and ascends medially and obliquely below the
inferior oblique muscle. It then passes through the semispi-
nalis and trapezius muscles running subcutaneously in the
occipital region. During its initial course it gives branches
for the inferior oblique, semispinalis, longissimus capitis,
splenius, and trapezius muscles. It also spreads two collateral
branches that anastomose with the dorsal branch of cervical
nerves 1 and 3.
The dorsal ramus of cervical spinal nerve 3, outside the
intervertebral foramen, runs backward toward the vertebral
recesses and divides into a medial and a lateral branch. The
medial branch runs upward medial to the greater occipital
nerve, supplying the skin of the nuchal region.
The lesser occipital nerve and the great auricular nerve
originate from the cervical plexus. They pierce the superficial
cervical fascia posterior to the sternocleidomastoid muscle.
The lesser occipital nerve originates from the middle cer-
vical ganglion. It ascends along the posterior margin of the
sternocleidomastoid muscle, and supplies the skin of the
occipital and mastoid regions.
The great auricular nerve has the same origin and follows
the same path as the lesser occipital nerve to finally reach the
auricula. It is responsible for the sensibility of the posterior
auricular region, the ear lobe, and the angle of the
mandible.
The temporal region is innervated by the auriculotempo-
ral nerve, a branch of the mandibular division of the trigemi-
nal nerve. It originates from the posterior division of the
mandibular nerve with two roots that encircle the middle
meningeal artery. It passes medially to the neck of the man-
M. Toscani and M. Ciotti
dible, and reaches the parotid lodge, passing through the
parotid gland.
It turns superiorly, outward, between the external auditory
meatus and the superficial temporal vessels, spreading
branches to the skin of the temporal region and the anterior
part of the auricle [21–23].
8 First Visit and Patient Selection
The first doctor-patient approach aims at giving both of them
information. For the doctor it is important to evaluate the
psychological aspects of the patient, determine the motiva-
tions behind the surgical operation, and discuss the possible
expectations. As a consequence, the surgeon must suggest
the best strategy without promising miraculous results. He
should rather find the best solution in every case, considering
the patient’s expectations, degree of baldness, age, and den-
sity, color, and quantity of hair. The doctor should give sim-
ple, complete, and exhaustive explanations and verify that
these are well understood by the patient. During the inter-
view the patient can be accompanied by relatives or friends.
Such company, in fact, facilitates a more serene and cordial
interview and puts the patient at ease.
The questions can then be addressed to the accompanying
person, and/or can be better explained and understood. It is
important to plan the interview in different steps and sessions
in a cooperative and friendly ambience. The information
given should be quantitatively adequate for the patient.
Patients who have already undergone surgical hair trans-
plantation are already informed about several aspects.
Therefore, they require less interview time than non-operated
or poorly and badly informed patients. In these cases, the
interview will aim at informing the patient about the new
surgical methods and the more natural results that can be
obtained.
The first visit, therefore, is a fundamental communicative
process through which the patient expresses his expectations
and objectives, while the surgeon must explain in a realistic
way the achievable short- and long-term results and the dif-
ferent available techniques.
Sometimes, the surgeon has to deny the operation to a
certain percentage of patients with unrealistic expectations
based on the results that can be obtained.
8.1 Medical History
The collection of the medical history is fundamental, allow-
ing in each patient the identification of:
• Family history of baldness, especially in the father, grand-
fathers, uncles, and brothers
General Concepts and Indications
• The modality of onset and chronological evolution of
baldness (the precocious development is a negative prog-
nostic factor)
• Previous medical or surgical treatments and their results
• General conditions of the patient
• Possible thyroid or metabolic dysfunctions
• Possible oligoelement deficiency (iron, zinc, copper,
selenium)
• Psychism
• Tobacco, food, and drug consumption
• Possible use of prosthesis or hairpiece
In women, signs of hormonal dysfunctions are also
investigated.
8.2 Physical Examination of the Scalp
The physical examination of the scalp aims to:
• Evaluate the entity of baldness
• Determine the possibilities of treatment and plan the most
appropriate technique
• It is important to evaluate:
• The diameter of the hair shaft
• The density at the donor area (>80 FU/cm2: good candi-
dates for transplantation; <40 FU/cm2: inadvisable
transplantation)
• Hair resistance to traction at the donor site (pull test)
• Hair color
• Hair shape (curly or straight)
• Elasticity and extensibility of the scalp
• Thickness of the scalp
• Possible local diseases (seborrheic dermatitis, keratosis,
lichen, etc.)
• Presence of pre-existing scars
Usually the Hamilton classification is used for men and
the Ludwig classification is used for women. At the end of
the physical examination, the physician has obtained an idea
of the evolutionary trend of alopecia. It is important to warn
patients that because of the progressive character of alopecia,
especially in young subjects, the predictive value of future
hair loss is very low. As a consequence, further operations
may be necessary over the following years for the loss of
non-transplanted hairs.
8.3 General Principles
8.3.1 Hairline Design
We must not surrender to a patient’s insistent requests for
coverage of the receding hairline and the advancement of the
535
frontline. Considering that transplanted hair will not fall out,
it is the surgeon’s task to realize a hairline that appears natu-
ral at every age.
The design (Fig. 10) is performed by drawing a middle-
frontal point H 7–10 cm above the nasofrontal angle (accord-
ing to the height of the forehead and the degree of baldness).
In extensive baldness it is advisable to draw back this point
H, even more than 10 cm.
Starting from point H, we draw on both sides a convex
arcuate line reaching the peak of the temporal insertion line
(vertical projection of the lateral canthus) by tracing a C or a
U [24].
The hairline design should be as natural as possible. It is
never too posterior. Moreover, it is always possible to move
forward a hairline that is too rearward, but not the opposite.
8.3.2 Hair Direction
To achieve a natural result and hair that is easy to comb, we
should try to obtain forward-oriented hair. Therefore, to
cover the anterior regions by means of a flap it is advisable to
use a superior pedicle flap that transposes forward-oriented
bulbs (this explains the progressive relinquishment of the
inferior pedicle flaps). With grafts, the natural hair direction
and an acute engraftment angle of around 30–45° are
respected (Fig. 11).
8.3.3 Infiltration
Local anesthesia is performed with lidocaine or mepivacaine
plus adrenaline (for a good hemostatic effect and to reduce
the anesthetic dose) diluted with, possibly, refrigerated
sodium chloride. Some authors recommend adding sodium
bicarbonate to temper the acidity and reduce pain during
infiltration. However, this expedient can cause more swelling
in the postoperative period.
Nerve blocks are useful because they help reduce the
number of injections of local anesthesia. They are mainly
performed on the supraorbital, supratrochlear, auriculotem-
poral, and greater and lesser occipital nerves. The local anes-
thesia is performed gradually until the operating area whitens
and is in tension, to facilitate the incision.
8.3.4 Orientation of the Incisions
A scar is more evident if the hair diverges upon it. For the
Hippocratic wreath, a horizontal orientation determines a
less visible scar (hidden by overlying hair); an oblique arcu-
ate scar is less visible than a vertical scar (more difficult to
disguise). For the vertex (Fig. 11), it is necessary to orient the
hair growth angle to reproduce the natural hair whorl.
8.3.5 Respect of Hair Bulbs
To avoid the creation of hairless percicatricial areas, the ori-
entation of the surgical blade should consider the hair orien-
tation, being parallel to its growth angle.
536 M. Toscani and M. Ciotti

Fig. 10 Hairline design. We draw the point H and a point G on each side in correspondence with the vertical line passing along the lateral canthus,
then we draw an arcuate line to unite these points

Fig. 11 Natural hair direction. From the vortex area, the hair is oriented forward on the upper part and downward on the sides and posteriorly
General Concepts and Indications
The hemostasis of the margins of the incision, when
performed with the electrosurgical pencil, should not be
performed on the small vessels of the deep dermis because
the coagulation can damage the hair bulbs. Only the vessels
of the galea must be coagulated in a selective manner.
8.3.6 Role of the Galea
A solid anatomical landmark during the dissection (that is
performed in the Merckel space), the galea offers a protec-
tive plan to the hair bulbs in the cephalic portion of the scalp.
It guarantees, via its vessel-bearing role, vascular safety for
the flaps (the supragaleal network reinforces the dermal and
subdermal networks).
8.3.7 Different Sutures
The two structures that offer a mechanical resistance are the
dermis and the galea. The sutures should therefore anchor on
one of these two elements and respect the hypodermis so as
not to damage the hair bulbs.
8.3.8 Tension of the Sutures
Special attention must be paid to avoid an excessive tension
on the sutures, as this can cause:
• Delayed wound healing
• Wound dehiscence
• Transient effluvium followed by hair regrowth
• Permanent alopecia of the margins due to necrosis of the
hair bulbs
• Necrosis of the margins with healing by second intention
and subsequent permanent cicatricial alopecia
References
1. Alonso L, Fuchs E (2006) The hair cycle. J Cell Sci 119:391–393
2. Hamilton JB (1951) Patterned loss of hair in man: types and inci-
dence. Ann N Y Acad Sci 53:708–728
3. Norwood OT, Shiell RC (1984) Hair transplant surgery. CC
Thomas, Springfield
537
4. Ludwig E (1977) Classification of the types of androgenic alopecia
(common baldness) occurring in the female sex. Br J Dermatol
97:247–254
5. Morestin H (1911) La réduction graduelle des difformités tégumen-
taires. J Chir (Paris) 8:509–538
6. Passot R (1920) Les autoplasties esthétiques dans la calvitie. Presse
Med 23:222–223
7. Okuda S (1939) Clinical and experimental studies of transplanta-
tion of living hairs. Jpn J Dermatol Urol 46:135–138
8. Orentreich N (1959) Autograft in alopecias and other selected
dermatological conditions. Ann N Y Acad Sci 83:463–479
9. Juri J (1975) Use of parieto-occipital flaps in the surgical treatment
of baldness. Plast Reconstr Surg 55:456–460
10. Nataf J (1984) Surgical treatment for frontal baldness: the long
temporal vertical flap. Plast Reconstr Surg 74:628–635
11. Nataf J (1978) Lambeaux du cuir chevelu et étude comparative avec
les autres techniques de transplantation. Ann Chir Plast Esthet
23:176–182
12. Ohmori K (1980) Free scalp flap. Plast Reconstr Surg 65:42–49
13. Brandy DA (1986) The bilateral occipito-parietal flap. J Dermatol
Surg Oncol 12:1062–1068
14. Marzola M (1984) An alternative hair replacement method. In:
Norwood OT (ed) Hair transplant surgery. CC Thomas, Springfield,
pp 315–324
15. Dardour C (1985) Treatment of male pattern baldness with a one
stage flap. Aesthetic Plast Surg 109:109–112
16. Dardour JC (1989) Les reductions de tonsure, principles et innova-
tion: le lifting du scalp. Ann Chir Plast Esthet 34:234–242
17. Limmer BL (2004) The history of follicular unit micrografting
technique: a personal view. In: Unger W, Shapiro R (eds)
Hair transplantation. Marcel Dekker Publishers, New York,
pp 383–388
18. Uebel OC (1991) Micrografts and minigrafts: a new approach for
baldness surgery. Ann Plast Surg 27(5):476–487
19. Fréchet P (1993) Scalp extension. J Dermatol Surg Oncol 19:616–622
20. Fréchet P (1994) Traitement des calvities étendues. Phase ultime du
traitement par réduction de tonsure avec correction de la fente
alopécique occipitale au moyen de trios lambeaux de transposition.
Rev Chir Esthet Lang Fr 75:43–50
21. Netter FH (2007) Atlante di Anatomia Umana. Masson Editore,
Milan, Italy
22. Tremolada C, Candiani P, Signorini M, Vigano M, Donati L (1994)
The surgical anatomy of the subcutaneous fascial system of the
scalp. Ann Plast Surg 32:8–14
23. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ (1991) The
surgical anatomy of the scalp. Plast Reconstr Surg 87:603–612
24. Shapiro R (2004) Principles and techniques used to create a natural
hairline in surgical hair restoration. Facial Plast Surg Clin North
Am 12:201–217
 Hair Transplantation
Marco Toscani and Mariangela Ciotti
Nowadays hair transplantation is the most commonly used sur-
gical technique to treat androgenetic alopecia. It is performed
on an outpatient basis with only a small risk of failure. The
result can be appreciated only after a few months when the
grafted bulbs have regenerated hair, and limited density may
require further operations to achieve the desired effect.
Relative contraindications are advanced or very young
age, diabetes, systemic diseases, cardiovascular diseases, or
local disorders of the scalp.
Sessions are usually performed under local anesthesia,
with or without sedation, depending on the patient and the
estimated duration of surgery.
1 Historical Background
The theory of “donor dominance” arose after the publication of
Orentreich’s observations regarding the autotransplant method
in 1959. This theory states that grafted bulbs continue to show
the characteristics of the donor site, i.e., hormone insensibility,
after they have been transplanted to different sites [1].
By developing this theory, several investigators created
different instruments to improve the harvesting and implant-
ing technique while making it easier and faster.
For instance, punches were connected to the handle of a
dental micromotor to allow harvesting of multiple grafts in a
shorter time. The caliber was restricted to 5 mm, as bigger
grafts would cause central avascular necrosis and lead the
loss of the bulbs. At least three surgical sessions were recom-
mended to enable disguise of the inevitable “pluggy” effect
when the transplanted hair started to grow, which, especially
M. Toscani, MD (*)
Ricercatore Universitario di Chirurgia Plastica, Dipartimento
di Chirurgia, Università di Roma “Sapienza”, Rome, Italy
e-mail: marcotoscani@libero.it
M. Ciotti, MD
U.O.C. di Chirurgia Plastica, Università di Roma
“Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_38
at the hairline, caused an unnatural aspect known as a “doll’s
head” appearance.
Donor sites healed by second intention caused cicatricial
thinning with large wastage of bulbs, which compelled
patients to wear long hair or undergo further operations to
remove cicatricial areas. For these reasons the technique
became rather unpopular.
In the 1980s Marritt and Nordstrom described the dissec-
tion of grafts containing 1–2 bulbs to improve the aspect of
the hairline, while Uebel applied this technique to the whole
scalp with a variation of the “stick and place” method, con-
sisting of the insertion of the graft immediately after each
incision [2–4].
Since the 1990s, with the assistance of new microsurgical
instruments, magnifying glasses, and microscopes for hair-
follicle dissection, transplantation with mini- and micrografts
has been carried out worldwide with natural-appearing results.
Microscopic studies on hair growth patterns revealed that
hair naturally grows in clusters of 1–4 hairs, leading to the
concept of the follicular unit (FU). Consequently, dissection
of the strip harvested from the donor site was introduced,
paying special attention to respect the growth sequence so as
to maximize transplanted hair growth without damaging the
bulbs and obtain a satisfactory result.
The number of grafts inserted at each session varies
according to the surgeon and the patient. To cover a certain
area, the number of the grafts used and the density of implant
is in inverse proportion to their diameter. At present, most
surgeons tend to cover large areas of baldness during mega-
sessions that allow the positioning of 1,500–4,000 micro-
grafts of FU containing from 1–3 hairs, while minigrafts
containing from 3 to 5 hairs are used to create fullness.
1.1 Preparation for Surgery (Authors’
Technique)
At the time of the surgery scheduling, the patient is given a
form containing the preoperative guidelines (Table 1).
539
540 M. Toscani and M. Ciotti

Table 1 Preoperative guidelines

Do not take aspirin and its derivatives or other NSAIDs 14 days before surgery. Such drugs can alter blood coagulation and cause excessive
bleeding during surgery. In case of doubt, ask your doctor
Do not drink alcohol 4 days before surgery. Alcohol slows blood coagulation, causes vasodilation, and can make the whole procedure more
difficult
Do not take vitamin E or B complex 7 days before surgery: these vitamins can slow blood coagulation
In order to improve blood coagulation, take vials of tranexamic acid diluted in half a glass of water twice a day, 1 week before surgery
Wash your hair the morning of surgery. Do not use hair products such as mousse, gel, etc
Do not cut your hair in the posterior part of your head before surgery. This would make it more difficult to hide the suture. If possible, let
your hair grow longer
Drink many liquids and have a light meal the night before surgery
Avoid caffeine the morning of surgery: relaxing drugs that cannot be taken with caffeine will be administered during surgery
Do not eat at least 5 h before surgery
Wear comfortable clothes, large trousers, button-up shirt, bring a baseball cap, a bandana or something similar to wear after surgery to go home
N.B. Local anesthetics, sedatives, and other drugs are usually administered during surgery and may remain in the circulation for some hours
after the operation, therefore we recommend that the patient is accompanied and avoids driving

2 Description of the Surgical Operation

• On the patient’s arrival the analyses are checked, the con-

sent form is signed, and preoperative photos are taken
• The patient is introduced to the surgical team
• One tablet of clonidine, 150 mg (Catapres) is adminis-
tered almost an hour before surgery as antihypertensive
and mild sedative
• The markings of the area to be transplanted are carried out
as previously agreed with the patient
Hairline design:
– Regarding hairline design, the concepts described in
general principles are valid; it is good practice to ask
the patient to bring a photo taken some years before
the hair loss to recreate, if possible, the original hair-
line; this request is always appreciated by the patients.
Moreover, after marking the hairline, possibly in
front of a mirror to make sure that the patient agrees,
small irregularities and cusps are created to obtain a Fig. 1 Preoperative drawing of the strip to be harvested at the donor
more natural aspect (everything that is too “sharp” site
and “perfect” appears false).
• Donor site preparation: hair is cut at the area where the follicular units needed for the transplant, and hair
strip should be harvested, marking out the strip. thickness and density (the average density in the occip-
When choosing the donor site it is important to respect ital region ranges from 50 to 160 FU/cm2). The size of
some basic principles: the strip should be calculated according to the require-
– Considering that androgenetic alopecia is a progres- ments, including a small percentage of excessive tis-
sive and often unpredictable disease, especially in sue, with consideration of the possible waste that may
young patients, it is important to envision the pos- occur during dissection.
terolateral area that may remain if the patient was to – After cutting the hair in this area to a length of 3–4 mm,
progress to Hamilton class VI or VII with age, and the markings of the strip are drawn, making it longer if
draw the markings of the horizontal strip using a ruler necessary, but not exceeding 1.5–1.8 cm in width
in the middle of this area extending from one ear to (Fig. 1).
the other. – Beginning of preliminary phases: while wearing the
– It is important to evaluate skin elasticity, whether the gown the patient lies on the operating table, the anes-
procedure is primary or secondary, the number of thetist evaluates the vital signs (pulse rate, blood
Hair Transplantation
pressure, oxygen saturation), and an intravenous line is
placed into a peripheral vein to administer fluids dur-
ing surgery.
– An antiseptic agent is then applied to the whole scalp.
• Local anesthesia is administered at the donor site.
The infiltration has a dual purpose:
– To obtain scalp insensibility for the duration of the
entire procedure
– To reduce perioperative bleeding
We generally use a cold (+4 °C) 2 % solution con-
taining 2 % lidocaine or 2 % mepivacaine with
1:80.000 adrenaline, if the patient’s pressure and car-
diologic conditions allow.
In anticipation of a mega-session, it is preferable to
combine lidocaine with 0.5 % bupivacaine, which has
a longer anesthetic effect. It is permissible to add a
small quantity of sodium bicarbonate (maximum 10 %
of the anesthetic solution) to reduce the acidity and, as
a consequence, the pain during infiltration.
We use fine needles of 27 or 30 gauge, and progres-
sively infiltrate the entire surgical area in a double
layer above and below the galea aponeurotica until the
area to be cut whitens and stretches.
• Tumescence
Excessive bleeding can make the whole procedure
more difficult and even compromise the final result. To
reduce the bleeding as far as possible, it is useful to per-
form tumescence using refrigerated 0.9 % sodium chlo-
ride with 1:200.000 adrenaline. This is also performed in
a double layer above and below the galea (epigaleal and
subgaleal) and allows a pressure ischemia (because of the
injected liquid) and a vasoconstriction (because of
the cold and the adrenaline); it creates greater tension in
the scalp, making easier the incision with the surgical
blade (Fig. 2). Moreover, it reduces the possibility of
damaging subgaleal vessels and nerves at the donor site
by moving them away from the incision point.
Fig. 2 Tumescence in the frontal region
541
3 Harvesting Techniques
The harvest is facilitated by positioning the patient prone
with the head bent on an appropriate pillow. Harvest using
the trephine or motor-driven punch has been almost aban-
doned, as it led to substantial wastage of bulbs.
At present, most surgeons prefer to perform the excision
of a strip of scalp, which is later cut into grafts. Technical
variations basically concern:
• Use of a single-bladed scalpel
• Use of a multiple-bladed scalpel (3–6 parallel blades) that
allows a harvest of 2–3 mm wide strips according to the scal-
pel specifications. This has the advantage of expediting the
dissection of follicular units, but leads to a lower yield because
it damages a greater number of bulbs at the donor site.
The incision, which is performed along the already drawn
lines, must be sharp. We use a #10 blade and go as deep as
necessary to harvest the hair follicles without damaging the
vasculo-nervous structures underneath.
During the harvest, the blade must be inclined with an
oblique projection upward, parallel to the hair, to respect the
angle of growth of hair follicles at the donor site (~30°) and
to avoid damage to or sectioning of the bulbs (Fig. 3).
Once harvested, the strip is placed in cold 0.9 % sodium
chloride and delivered to the assistants, who start the dissec-
tion under microscopic guidance.
The hemostasis of the donor site must be focused on
galeal vessels, paying special attention to avoid damaging
the bulbs in the subcutaneous layer with heat from the elec-
trosurgical pencil.
As already mentioned under general principles, utmost
attention must be paid to avoid excessive tension at the sutures.
The closure may sometimes require minimal detachment to
allow the wound margins to adapt, although in cases of second-
ary procedures the detachment is larger and mandatory.
Fig. 3 Incision of the donor site
542 M. Toscani and M. Ciotti

Fig. 4 De-epithelialization of the superior edge of the incision to per-

form the trichophytic suture

Fig. 6 Scar at the donor site

Fig. 5 Suture of the donor site

In 2005, Frechet and Marzola described a new kind of

suture called “trichophytic.” This technique consists of trim-
ming 1–2 mm of epidermis from the superior border of the
wound or, more rarely, from the inferior border. These
authors maintain that by de-epithelializing one of the mar-
gins the hair will grow through the scar, making it less linear Fig. 7 Section of follicular units
and visible [5, 6] (Fig. 4).
The suture can be performed in two layers with deep
absorbable sutures, or in a single layer with a 3-4/0 nylon
running suture. Metal clips, as used by several authors, lead 10–12 months between the procedures to allow the scalp to
to a more painful postoperative course (Fig. 5). regain elasticity (Fig. 6).
In secondary procedures it is common for expert surgeons
to perform the removal of the previous scar tissue by includ-
ing it in the strip, so that the patient has a single final scar. 4 Graft Preparation (Slivering)
This, however, exposes the patient to the risk of undergoing
suturing of inelastic tissue under tension, with the possibility The preparation of the grafts must be absolutely atraumatic
of scar dehiscence. To avoid this, the surgron is recom- and must pay due consideration to the bulbs, which are pre-
mended to perform proper detachment of the margins, care- vented from drying by dipping them into low-temperature
fully suture the subcutaneous tissue, and allow at least 0.9 % sodium chloride or lactated Ringer’s solution.
Hair Transplantation
Fig. 8 Dissection of follicular
units via overhead projector
The first step consists of using a #23 blade or apposite
rectangular blades to cut several parallel slivers of scalp of
1.5–2 mm width, respecting the direction of the hair. The
dissection is performed on dedicated overhead projectors to
enable the surgeon to obtain a better view of the single seg-
ments to be treated, demonstrating the fat that needs to be
removed by transparency.
These segments are then cut with the help of the micro-
scope or microsurgical loop. According to the needs of the
recipient area it is possible to obtain: monobulbar micro-
grafts with a single hair; micrografts of 1–1.5 FU, each com-
posed of one, two, or three hairs; minigrafts of 1.5–2 mm
with four to five hairs each; and bigger grafts of 2–3 mm
(Figs. 7 and 8).
The excessive galeal and deep fat tissue below the bulbs is
then eliminated, and rinsing with sodium chloride removes the
keratin remaining. The grafts are then counted and aligned,
according to their size, on wet gauze in a Petri dish (Fig. 9).
5 Transplant Technique
After moving from prone to supine or semi-seated position,
local anesthesia is performed along the new hairline
delineation.
The infiltration of the recipient area is performed accord-
ing to the same principles as for the donor area. To achieve
more effective anesthesia in the frontal region, it is possible
to perform nerve blocks at the emergence of supraorbital and
supratrochlear nerves. However, we have abandoned this a
technique because the minimal advantage is offset by the risk
of injuring nearby vessels, creating significant and irritating
periocular ecchymosis.
Regarding the tumescence with cold adrenalinated
sodium chloride in this area, surgeons’ opinions are divided.
Although some prefer not to perform it to avoid the excessive
543
swelling of the frontal region that may occur in the postop-
erative period,, we always perform it in view of the impor-
tance of reduced bleeding in achieving a good outcome.
Moreover, by stretching the scalp, it facilitates the incisions
of recipient sites and distances the subgaleal vessels.
The creation of recipient sites can be performed in several
ways.
• Frustule (punch, trephine): This technique consists in the
removal from the donor area of a cylinder of scalp to sub-
stitute it with a bulb-dense graft. Now almost abandoned
in standard situations, it is successfully used for the
removal of scar tissue or malpositioned grafts.
• Specific scalpels with dedicated blades that allow the
incision without damaging the bulbs that may be present
(there are several instruments and blades on the market
for all surgeons’ needs, such as the lanceolate needle,
simple 16, 18, 19, and 21 gauge needles, Nokor needle,
and the Sharpoint blade with different degrees of angle)
(Fig. 10a, b).
The hair transplanter developed by Choi allows creation
of a hole and insertion of a bulb at the same time, but requires
extra time for the introduction of the bulb into the instrument
by trained personnel [7].
To create holes with minimal bleeding, the use of a CO2
(carbon dioxide) laser was been proposed, but later aban-
doned because it led to greater local damage and slower
growth of the grafted hairs [8].
The incisions at the recipient sites are oriented to respect
the natural direction of the hair growth, with an anterior
direction and an attachment angle of around 30–45° in the
frontal and anterior region and 15–20° downward in the lat-
eral regions and sideboards.
The dimension of the incisions in the recipient sites
depends on those of the grafts to be inserted. Once posi-
tioned, the grafts are kept in place by the pressure created by
544
the cutaneous margins of the incision and by the fibrin. When
all of the grafts are in place, the last check is carried out
before dressing the wound.
6 Tips and Suggestions
In the frontal region, to obtain natural results we recommend
starting the hairline with 3–4 lines of monobulbar micro-
grafts before inserting the minigrafts. This technique fur-
Fig. 9 Preparation of mono-, bi-, and tri-bulbar grafts on wet gauze
Fig. 10 Surgical instruments
M. Toscani and M. Ciotti
nishes the hairline with a gradual effect and avoids the
doll’s-head effect that occurs when oversized grafts are
inserted in the frontline.
A rule of thumb in the design of the hairline is to create
some cusps to make it irregular, as it would appear natu-
rally, while in the crown area the incisions should be ori-
ented by following the natural vortex or, if absent, by
recreating it.
When all the incisions have been performed, we proceed
with insertion of the grafts. Some surgeons prefer making
the incision and immediately inserting the graft in the
recipient site while the needle (or the blade) is pulled out
(stick-and-place technique) [2]. This technique allows bet-
ter control of the possible bleeding, even if less precise
because it does not allow prior estimation of the number of
grafts to be inserted or a comprehensive view of the remain-
ing work.
The graft insertion phase is delicate because the posi-
tive outcome of the operation greatly depends on it. It is
important to carefully choose the hairs to be inserted, pay-
ing attention to place in the frontline the thinnest monobul-
bar hairs and then gradually thicker monobulbar hairs, all
in the correct orientation. These criteria should be espe-
cially respected in patients with black or dark hair and
white complexion; in patients with white, grizzled, or fair
hair it is possible to insert some bibulbar grafts in the
frontline as well.
In hair density-increasing procedures and in women, in
whom the hairline is preserved, the insertion of monobul-
bar grafts would not confer the required density; therefore,
we suggest directly using the follicular units with 3–4
hairs or even bigger grafts in cases of very light or grizzled
hair.
Hair Transplantation
If bleeding at the bottom of the graft causes its extrusion, the
surgeon must return to this area and reposition the graft, apply-
ing a moderate compression for a few minutes using gauze.
For every graft, we suggest to always check the depth of
implant: a graft that is too superficial tends to come out (tent-
ing), while a graft that is too deep may develop microcysts,
ingrown hair granulomas, or unaesthetic infundibula at the
base of the hair (“pitting”).
Finally, it is important to check the correct orientation of
the grafts in the recipient site as described by the general
principles; if not properly oriented, it is necessary to rotate
the graft 90° or 180° [9].
7 Dressing
In the absence of bleeding, the head may be left free of dress-
ing. This is the preferred option because the fibrin scab,
which keeps the grafts in place, is formed more rapidly in
contact with air. If a mild hemorrhage persists, some prefer
to place a moderately compressive wet dressing for a few
hours or even until the day after.
8 Postoperative Medical Therapy
During the postoperative period, wide-spectrum antibiotics
are administered for 1 week and painkillers as needed, in
addition to betamethasone to reduce the swelling in the fron-
tal region, which typically occurs within the first or second
postoperative day. The patient is advised to sleep with the
head elevated by two pillows for the first days. The day after
the operation, the head is washed with a gentle shampoo by
the medical team while checking the position of the grafts,
and if necessary those that are partially exposed are replaced.
9 Postoperative Course
From the day of surgery and during the following 3
months: As early as the second postoperative day, small
scabs start to form next to each graft. After cleansing with
gentle shampoos, around 10–15 days later the scabs fall
off progressively, leaving the scalp in the preoperative
condition.
The forehead and eyelid edema that can occur around the
second or third postoperative day resorbs within a few days
with the aid of cortisone therapy.
Despite an initial growth of 2–3 mm, an effluvium of
transplanted and neighboring hairs usually occurs. This
545
thinning typically occurs 3 weeks after surgery, and is fol-
lowed by hair regrowth starting from the third or fourth
postoperative month. The application of products such as
minoxidil seems to reduce the thinning and to speed the
growth of new hair.
Three to4 months later: Most patients notice the hair
growth around the third or fourth postoperative month.
Although this is the normal time frame for hair growth, every
patient can react in a different manner: for some patients the
hair growth begins earlier, for others later.
The hair growing in this period represents approximately
60 % of the final growth. With the passing of time, other hair
will grow and become thicker, longer, and darker. After sur-
gery the patient may feel an itch in the grafted area or reduced
sensibility in the donor area, but such symptoms tend to dis-
appear within a few months.
The incision in the donor area is perfectly healed, but the
scar remains in the remodeling phase and continues to
improve over the following months.
Five to 6 months later: A significant change usually
occurs between the fourth and sixth month, after which most
hair (70–80 %) should have penetrated the skin thickness and
the patient will have reached almost 80 % of the final aes-
thetic result.
Twelve months later: The hair growth is complete, show-
ing the final aesthetic result.
10 Advantages
• Outpatient surgery, not demanding for the patient
• Natural aspect of the final aesthetic result without “doll’s
head” effect as when using the islands and multifollicular
grafts of the old technique
• Repeatable over the years according to individual
needs
• Grafts can be placed in the thinning areas without provok-
ing the loss of pre-existing hairs among which they are
inserted
• Minimal scar in the donor site
• Rapid healing and return to everyday life
11 Disadvantages
• Long and technically demanding surgical procedure
• Possible need of several operations to obtain an adequate
density
546 M. Toscani and M. Ciotti

• Need for specific instruments
• Need for numerous and specifically trained staff
12 Complications
The follicular transplant, if carefully performed, is a safe
technique and has a low complication rate. However, a spec-
trum of common surgical complications may occur:
• Irregularities of the skin surface (pitting and tenting): In
the former case the grafts are placed too deep, while in
the latter they are too close to the surface. It is possible
to correct these irregularities by inserting further grafts
in between, paying close attention to the depth. It is pos-
sible to repair tenting with dermabrasion of the area,
while for pitting it may be necessary to surgically excise
the graft

• Infections: Rather infrequent event if prescribed antibiot- 13 Clinical Cases

ics are taken and hygienic rules are observed
• Hematomas and ecchymosis: Rare; more frequent in sec-
ondary surgeries, hypertensive patients, or subjects under
a
anticoagulation therapy
• Wound dehiscence and partial necrosis: More frequent in
patients with inelastic scalp, smokers, and secondary sur-
geries. The necrosis may occur in cases of compromised
blood supply, the placement of grafts very close to each
other, placement in the middle of the scalp where the ves-
sels are at their most distal extremity, or in the presence of
previous surgical scars
• Pre-existing hair loss: Occasionally in the case of hair
density-increasing procedures or in women, pre-exist-
ing hair in the recipient site may fall out. This
phenomenon is unpredictable; in the majority of cases
it is transient and the hair regrows after a few months
along with the transplanted hair. However, sometimes b
the regrowth is partial and makes more visible the root
of the implant, making it necessary to perform a sec-
ond “touch-up” operation with monobulbar grafts to
disguise this effect
• Microcysts, pustules, furuncles, folliculitis: May occur in
the recipient area at the base of the implanted follicles,
especially in people with oily scalp or curly hair. The
causes can be the insertion of two grafts one over the
other, or their placement in very deep recipient sites. They
may disappear spontaneously or may require surgical
excision
• Loss of sensibility: After surgery an alteration or tempo-
rary loss of sensibility in the donor area may occur, and in
some cases may even last several months Fig. 11 (a, b) Clinical case 1 before and after hair transplantation
Hair Transplantation 547

a b

Fig. 12 (a, b) Clinical case 2 before and after hair transplantation

a b c

Fig. 13 (a, b) Clinical case 3. Preoperative view showing a marked thinning at the vertex, preoperative design following hair orientation, postop-
erative view after hair transplantation

ognomy. Hair transplantation is the best treatment option to

14 Hair Autotansplantation in Ectopic
Areas: Eyebrow Reconstruction
There are several causes that can alter the normal mor-
phology of the eyebrow. Post-traumatic scars, surgical
outcomes, and imprudent use of products or devices for
depilation are the most common conditions leading to par-
tial or total alopecia [10].
Such conditions often cause psychological discomfort
because of the importance this area assumes in facial physi-
obtain a natural and stable result in comparison with other
cosmetic procedures such as artificial hair implant or tattoo-
ing, which, however, does give acceptable results in women.
Accurate preoperative planning in tandem with a design
performed in relation to the contralateral eyebrow, in addi-
tion to sound patient information, are essential for positive
results (Fig. 14).
The harvest is performed from the low nuchal region,
where the hair is thinner, by removing a strip of scalp con-
taining an adequate number of hair bulbs for transplant.
548
Fig. 14 Clinical case-preoperative view of eyebrow transplantation
Fig. 15 Clinical case. Intraoperative view of eyebrow transplantation:
grafting of follicular units
The recipient area, after injection of local anesthetic with
adrenaline, is prepared to receive the monobulbar grafts
with mini-incisions using a Sharpoint needle of 15°
(Fig. 15). The incisions are performed respecting the angle
of the eyebrows’ bulbs and at a depth proportional to the
height. The use of magnifying devices and appropriate
microsurgical instruments is indispensable for the success-
ful outcome of the surgical procedure. The growth of grafts
is variable and ranges from 3 to 6 months (Fig. 16).
It is necessary to inform patients that, since these are fast-
growing hair bulbs, they have to be periodically cut.
In our experience, the surgical operation of hair transplan-
tation to the eyebrow, if performed in accordance with the
described principles, represents the gold standard in the
treatment of eyebrow alopecia.
M. Toscani and M. Ciotti
Fig. 16 Clinical case. Postoperative view 3–6 months after eyebrow
transplantation
15 Pubic Hair Restoration
The appearance of pubic hair is a sign of sexual matura-
tion in every society, so its absence can cause psychologi-
cal stress and a certain degree of intolerance in both sexes.
Hair loss in this region is often associated with chromo-
somal abnormalities, hormonal changes, or repeated trau-
mas. In some cases it can also be caused by the decision to
proceed to epilation for reasons of following transient
trends, only to later regret the result. In some patients
there is no true alopecia but a thinning of hair, leading to
a childish or aged aspect.
The donor area is typically the nuchal region. In our expe-
rience, initially the hairs maintain the characteristics of the
donor site and thus tend to grow longer than the other pubic
hairs, and are often straight. With the passing of time, the
patients report they do not have to cut them and notice a pro-
gressive curling [11].
When performing a hair transplant to the pubic region,
there are two important parameters to observe. Compared
with the scalp the increase in hair density must be less pro-
nounced, and it is necessary to recreate the masculine or
feminine distribution of hair. It is possible to refer to the
characteristics of each race or to guidelines specifically for
pubic hair restoration such as those described by Shinmyo in
2006 [12].
16 Follicular Unit Extraction
The follicular unit extraction (FUE) technique is a minimally
invasive method for hair restoration, as it is not based on the
use of scalp strips from the nuchal region.
Hair Transplantation
The FUE method does not include the so-called strip-
extraction procedures and, as such, no cut or scalp removal is
performed. Although the harvest of a single strip is an effec-
tive method for obtaining tissue from which the follicular
units can be extracted, it involves the formation of a linear
scar. If the technique is meticulously performed by harvest-
ing thin strips, the resulting scars will be unnoticeable, but if
the harvested strips are too large the scars may become unac-
ceptable. As a consequence, many patients are not willing to
undergo a procedure involving an extended linear scar that is
potentially difficult to treat.
By contrast, in the FUE technique it is necessary to shave
the patient’s head, although this is often not easily accepted,
especially by female patients.
In the mid-1990s, Bernstein et al. proposed to solve this
problem by directly extracting the follicular units from the
donor area using a small punch [13, 14]. However, this
method suffered from an excessive waste of bulbs resulting
from blind dissection during the extraction of the follicular
units. In fact, inattentiveness to the direction of hair growth
would lead to bulb damage.
Subsequently, Inaba’s technique was introduced. The
punch used in this method was almost identical, but the
approach consisted in only partially cutting the hair follicle
and gently removing the remaining part with the forceps.
Such an intuition led Rassman and Bernstein to refine the
technique of FUE by organizing it into two phases [15–17].
In the first phase, a sharp 1-mm punch is placed over the fol-
licular unit and is inclined with an angle that corresponds to
that of the hair growth under the skin surface.
A rotatory motion is effected on the punch and the skin is
then incised, isolating the follicular units in the epidermis
and superficial dermis.
In the second phase of the extraction, thin mouse-tooth
surgical forceps are used to apply a mild traction on the supe-
rior part of the follicular unit until this is detached from its
deep and subcutaneous dermal connections.
If a graft cannot be removed with a mild traction, its
deeper portion is separated from the surrounding tissue by
dissection using a thin needle (with a U-shaped extremity)
while a mild traction is impressed with the forceps. However,
with this technique, even with the best candidates, the pos-
sibility of resecting the follicle was high.
During an International Society of Hair Restoration
Surgery scientific conference, James Harris presented a vari-
ation of the surgical technique by adding a third phase [18].
In this three-phase procedure, initially a sharp punch is
used to make a groove in the epidermis, then a smooth punch
is used (with a backward movement) for the smooth dissec-
tion of the follicular graft from the epidermis and surround-
ing dermis [19].
549
Fig. 17 Surgical instruments for the FUE technique and follicular units
placed on gauze inside a dish
The use of a smooth punch avoids resection of the folli-
cles and allows easier extraction of undamaged follicular
units, also allowing retrieval of the distant follicles and
avoiding their resection (Fig. 17).
A disadvantage of the three-phase technique is the possi-
ble increase in the incidence of sunken grafts. Moreover,
some follicular units remain adherent to the subcutaneous
tissue and require a further dissection.
However, a huge advantage is that this technique is feasi-
ble even in subjects with very thin hair or African-like frizzy
hair. Since the procedure is performed blindly, visualization
no longer represents a problem, which broadens the indica-
tion even to subjects with gray hair that is usually difficult to
visualize.
As the subcutaneous position of the follicles cannot be
predicted in advance, the superficial incisions should not be
deeper than 0.3–0.5 mm so as to reduce the risk of involun-
tary resection. However, the depth of the superficial incisions
can be increased by 0.1–0.2 mm in subjects in whom the fol-
licles are slightly longer [20, 21].
To avoid resection of the follicle, in the case that the tilt
angle of the punch differs from that of the follicular unit, it is
possible to create superficial incisions with modified angles
to obtain a more precise estimation of the follicle’s
direction.
In the case of “capping” (separation of the follicle from
the epidermis and superficial dermis at the level of the seba-
ceous gland), it is possible to attempt a second passage with
the dissecting punch, catch the unit at the level of the seba-
ceous gland and pull it, or leave the graft in situ and let the
skin heal for second intention.
550
a b
Fig. 18 (a, b) Clinical case. Preoperative view of FUE with the presence of visible gulfs. Immediate postoperative result with the presence of
residual pinpoints in the donor area
Tumescence is not always necessary, and should be used
in moderation. In fact, sometimes it can even make the
extraction process more difficult. Such a process tends to be
generally easier in the occipital area of the scalp than in the
temporal areas where, because of a major adhesion of the
bulbs, manual dissection may be necessary.
In the case of a sunken graft, it is necessary to immedi-
ately apply pressure around it in an attempt to make it rise to
the surface. If the attempt fails, it is necessary to examine the
circular incision to identify the base of the follicle. If this is
not visible, small curved forceps should be used with the tip
directed toward the upper part of the incision in an attempt to
catch the follicular unit. If still impossible to localize the
graft, a small incision can be made in the upper part to create
a larger explorative breach. If, after these passages, the sur-
geon is still unable to visualize the graft, it should be left in
place.
Since the forceps we use are very thin, the FUE technique
only leaves a few pinpoints in the donor area, which can only
be noticed under close scrutiny. As such, a person who
undergoes an operation with the FUE technique can shave
his head in the following years without worrying that the
scars may be noticed (Fig. 18a, b).
It is technically possible to extract and transplant 2,000
grafts in a day without using a micromotor. Leaving the
extracted follicles more than 4 h outside the body in a special
solution should be avoided by limiting the number of grafts
to 1,200–1,400. Moreover, a transplant with 2,500–3,000
grafts can be performed in two sessions, leaving 1 day of rest
between the sessions [22–24].
M. Toscani and M. Ciotti
Although the studies did not reveal significant differ-
ences between the special solutions and the sodium chlo-
ride during the first 6 h, we prefer to keep the grafts in
lactated Ringer’s solution at +4 °C, thus improving the sur-
vival of hair follicles.
16.1 “Dense Packing”
Dense packing is a procedure consisting in the transplant of
follicular units with a density higher than 35 per square cen-
timeter (35 FU/cm2). However, most trichologist surgeons
prefer not to exceed 25 FU/cm2 because of the technical dif-
ficulties and more complicated engraftment [25, 26].
16.2 The Micromotor
The micromotor is an electric device with variable rotation
speed, also used by dentists. Recently the use of the micro-
motor in the FUE technique has become popular, as it allows
a more rapid extraction of the grafts.
After their insertion, the hair follicles slightly change
their direction. It is possible to feel this by pressing gently;
however, the heaviness of the handle makes it difficult to
identify the growth angle of the follicle. Moreover, the
rapid rotation damages the closer follicles, resulting in
major cicatricial outcomes. The manual method is there-
fore more precise, even if a micromotor takes less time to
finish the work.
Hair Transplantation
16.3 Indications
The FUE technique is indicated in the following cases:
• When even the presence of a linear scar is unacceptable
(subjects who shave their heads or always keep their hair
very short)
• When the patient expressly asks for the FUE technique
and it is possible to harvest a sufficient number of grafts
to satisfy his requirements
• In patients with limited hair loss or when short sessions are
necessary (patients with male pattern alopecia in Norwood
class 3 or with small areas of vertex baldness) [1]
• For limited aesthetic areas, such as the central points, the
eyebrows, the eyelids, and the mustache
• For limited areas of alopecia secondary to dermatologic
conditions
• In the treatment of wide cicatricial areas secondary to tra-
ditional harvest of the strip
• In patients with insufficient scalp elasticity for the exci-
sion of a strip
• In scarring processes caused by dermatologic conditions,
traumas, or neurosurgery procedures
• In subjects with donor areas extensively disfigured by scars
with subsequent difficulty to realize a linear incision
• In patients who tend to form wide or thick linear scars
• In patients excessively worried about pain or scars
• When the body or the beard is the donor area
16.4 Contraindications
The FUE technique is contraindicated in the following cases:
• Inexperience of the surgeon in such a technique
• Absence of appropriate instruments
• Unrealistic expectations of the patient
• Inadequate donor reserve
• Scar tissue that makes difficult for both the biphasic and
triphasic techniques
• Not perfectly performed harvest, with the residual pres-
ence of small white pinpoints that confer an unaesthetic
“moth-eaten” aspect, and resulting signs often more evi-
dent than after the traditional transplantation technique
• Extremely curly hair
17 Follicular Unit Transplantation
or FUE?
This is one of the most frequently asked questions. The
answer depends on the size of the bald area, elasticity and
hair thickness of the donor areas, and evaluation of future
551
hair regression in the frontal region. Both methods can be
used in combination to increase the possibility of extracting
more grafts from the donor area.
If the patient is unafraid of undergoing a surgical opera-
tion and does not plan to shave his head in the future, the
follicular unit transplantation technique is the best choice
because it takes less time and is economically more valid, as
it involves a much lower wastage of hair bulbs [27].
If the patient, instead, is reluctant to undergo a surgical
excision or there is the possibility of a further hair loss and
the donor area may have reached its limits, the FUE tech-
nique offers a good alternative.
Certainly the FUE technique represents interesting prog-
ress that graduates the field of hair transplantation surgery
closer to mini-invasive surgery [28]. The promise of an
almost scarless operation is alluring both for the patient and
the surgeon, even if this is not the case because in reality
there will be 1,000–2,000 diffuse, dot-like miniscars instead
of a linear one.
The FUE technique is certainly useful in an increasing
number of candidates for hair transplantation; nonetheless,
there remain problems regarding patient selection, healing of
the donor area for second intention after very long sessions,
and sunken grafts in the donor area.
The reasons for choosing the FUE technique instead of
the strip harvest can be the absence of a linear scar, the wish
for a theoretically pain-free outcome and more rapid recov-
ery, or simply the intention to undergo a slightly less invasive
procedure.
INFORMED CONSENT FOR HAIR
TRANSPLANTATION
I undersigned …………………………….. resident of
…………………….. do hereby authorize and give my con-
sent to dr. ……………………………… to perform a ses-
sion of hair bulbs’ transplantation necessary for the correction
of alopecia………………………………………. which I
am affected by.
I have been fully informed by dr. ……………………………
about the potentiality, the limitations and the possible need
of further surgeries.
I have been fully informed by dr. ……………………………
about the methods used in this operation and I authorize him to
perform any surgical procedure that becomes necessary during
the operation, using the personnel that he considers qualified.
Moreover, during the preoperative consultation I have
been explained the possible complications and outcomes of
the procedure:
1. I consent to undergo medical and physical therapies that will
be prescribed in the postoperative period, being informed
that otherwise I may compromise the procedure itself.
552
2. As surgery is not an exact science, I have not been prom-
ised or guaranteed good results: the final result cannot be
definitely predictable in advance. After surgery I will
have permanent and visible scars, whose extent is not pre-
dictable in advance (formation of visible, painful scars,
keloids, especially in dark-skinned or black people); the
quantity of regrown hair depends on a biological phenom-
enon influenced by individual characteristics. As a conse-
quence, the symmetry of the result and the formation of
skin irregularities do not only depend on the surgical
technique but also on the individual response.
3. The procedure, as all other surgical procedures, is subject
to the risk of below-mentioned complications that may
sometimes determine the need for further surgeries.
Possible complications: All common complications of
every surgical procedure such as:
– Infections: rather infrequent event if the prescribed
antibiotics are taken and hygienic rules are observed.
– Hematomas and ecchymosis: more frequent in sec-
ondary surgeries or subjects under anticoagulation
therapy;
– Wound dehiscence and visible scars: more frequent in
patients with inelastic scalp, smokers and secondary
surgeries.
– Pre-existing hair loss: sometimes in case of hair thicken-
ing procedures or in women it may happen that preexist-
ing hair in the recipient site falls out. This phenomenon
is unpredictable, in the majority of cases the hair regrows
after a few months along with the transplanted ones.
However, sometimes they do not all regrow, so it can
be necessary to perform a second touch- up operation.
– Microcysts: may occur in the recipient area at the base
of the implanted follicles, especially in people with
oily scalp or curly hair. The hair is ingrown and forms
a microcyst to be drained.
– Loss of sensibility: after surgery an alteration or tem-
porary loss of scalp sensibility may occur and in some
cases it may last even several months;
– Rare complications (partial list)
• Complete failure of growth of transplanted hairs
• Total loss of donor hair
• Permanent numbness of the scalp or persistent scalp
pain
• Loss of transplanted hair
• Keloid formation
• Arteriovenous fistula formation
4. Possible physical or aesthetic complications can be
treated, as such I consent to undergo the necessary treat-
ments, even surgical ones.
5. For female patients - I declare not to be pregnant.
6. I give consent to the administration of anesthetics and I
am aware that there are risks to life and health as conse-
quence of anesthesia.
M. Toscani and M. Ciotti
7. I am aware that the quantity and quality of my hair is a
primary factor for the final outcome of the procedure.
According to the privacy law, I consent to be taken pre-,
intra- and postoperative pictures, which will have popular-
scientific purposes.
I am signing this consent of my own free will and I believe
I have been well informed. Moreover, I understand that,
despite the commitment of Dr. …………………….. to oper-
ate with diligence and according to his knowledge and judg-
ment, the final results cannot be guaranteed because of
situations that are not related to the surgical procedure or
because of possible abnormal responses of my body.
I have been given the opportunity to ask all the questions that
I considered appropriate and received comprehensive explana-
tions which I totally understood and that I have been satisfied of.
Therefore, I completely approve the present authorization form.
Date, ………………………….
PATIENT’S SIGNATURE
……………………………………………………..…….
Document …………………………….....
References
1. Orentreich N (1959) Autograft in alopecias and other selected der-
matological conditions. Ann N Y Acad Sci 83:463–479
2. Uebel OC (1991) Micrografts and minigrafts: a new approach for
baldness surgery. Ann Plast Surg 27(5):476–487
3. Marritt E (1984) Single hair transplantation of hairline refinement:
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 Scalp Reduction
Martin G. Unger and Marco Toscani
Scalp reduction can be defined as the surgical excision of
redundant scalp tissue from one or more areas of alopecia of
the scalp. Since the 1930s, surgeons have used advancements
and/or rotation flaps to reconstruct scalp defects after areas
of malignancy or cicatricial alopecia have been excised. In
patients with larger defects, serial excisions were success-
fully used to remove areas that could not be excised in a
single operation. Although the field of scalp surgery contin-
ued to progress, including the development and design of
several types of transposition flaps, it was not until the mid-
1970s that the same techniques and principles became incor-
porated into the treatment of male pattern baldness (MPB).
Although “hair lifting” and “alopecia reduction” have
been used to describe this operation, the term “scalp reduc-
tion,” first used by Sparkuhl in 1978 [1], has now gained
widespread acceptance for this procedure. The combination
of hair transplantation together with one or more scalp reduc-
tions for hair restoration has served the profession well over
the years, and it is almost always performed in patients with
comprehensive baldness.
1 History
In the mid-1970s, independent of each other, Blanchard and
Blanchard [2, 3], Sparkuhl [1], Stough [4], and Unger and
Unger [5] all began performing scalp reduction surgery for
MPB. Blanchard and Blanchard [2] are credited with the first
scientific paper on this subject, which described a “hair
lifting” technique in 1976.
M.G. Unger, MD, FRCSC, ABCS, ABHRS
The Unger Cosmetic Surgery Center, Cosmetic Surgery Lecturer,
University of Toronto, Toronto, ON, Canada
M. Toscani, MD (*)
Dipartimento di Chirurgia,
Ricercatore Universitario di Chirurgia Plastica,
Università di Roma “Sapienza”, Rome, Italy
e-mail: marcotoscani@libero.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_39
A large series on scalp reduction was published by Bosley
et al. [6] in February 1979, and in December 1980, Alt [7]
published his first paper, making us aware that larger areas of
alopecia could be removed provided that extensive under-
mining, increased tension on closure, and galeotomies were
incorporated. Significant contributions to this field have also
been made by Norwood and Shiell [8], Nordstrom [9],
Marzola [10, 11], Brandy [12], and Frechet [13], in addition
to others who continue to modify and refine the procedure.
From a chronological point of view, the standard scalp
reduction was initially conceived, which in turn was fol-
lowed by the mini-reduction. Subsequently, following the
advent of tissue expanders, major scalp reductions have been
obtained. Many papers have been published on this topic,
such as the Frechet extender method [14] in 1993 and the
Unger PATE procedure [15] in 1995.
2 Scalp Reduction
2.1 Usefulness of Scalp Reduction
Scalp reduction, in combination with hair transplantation, is
most commonly used to improve the results of the surgical
treatment of androgenetic alopecia (AGA). The following
useful benefits can be achieved using this technique:
1. By keeping the same number of grafts and making the
area of alopecia smaller, it is possible to create an
increased hair density or, alternatively, to conserve a cer-
tain number of donor grafts for the future.
2. In patients where the AGA is affecting the mid scalp and
crown regions but not the anterior third, scalp reduction
can be considered as an alternative option to hair trans-
plantation or can delay it for several years.
3. In some patients, where the ratio of donor to receptor sites
may initially be inadequate for the desired amount of hair
transplantation, reduction of the area of alopecia may
result in a satisfactory ratio for treatment.
555
556
4. When the number of remaining donor grafts is very lim-
ited, the area of alopecia may be surgically reduced or
removed entirely by one or more reductions.
5. Scalp reduction may be used to elevate the superior bor-
der of the lateral fringe of normal hair on both sides or,
alternatively, on the part side alone. In some patients, it is
impossible to create a normal frontal hairline until the lat-
eral fringe on each side has been raised to allow the hair-
line to be relatively horizontal when viewed from the
side. In other patients, by elevating both sides or the part
side alone, the density of hair at the part is made cosmeti-
cally more pleasing.
6. In some patients, scalp reduction can be used to advance
the anterior temple hairline when previous hair loss has
occurred in this area.
Scalp reduction has also proved extremely useful in the
repair of areas of previous hair transplantation. It can also be
used to remove the hairless gap between previous grafts and
the lateral fringe when progressive hair loss has occurred.
Mini-reductions can be used to excise areas of alopecia
between rows of previously transplanted grafts.
Areas of poor graft survival or improper hair direction
from previous hair transplantation can be surgically excised.
If desired, satisfactory grafts can be removed from the area
before or (less preferably) after it is excised and implanted for
a second time into the remaining areas to be transplanted.
When there is good hair survival in the grafts but the
grafts have been spread too far apart or the area is too notice-
able in general, similarly, a portion of this area can be excised
and the grafts from within the area can be removed and trans-
planted for a second time.
When an area of alopecia occurs in the donor area of the
patient, a scalp reduction in the donor area can be carried out
to remove the area of alopecia.
Although scalp reduction is used most often to treat or
repair patients with AGA, it can also be used for the treat-
ment of those with postinflammatory or cicatricial alopecia,
lichen planopilaris, or burn patients, regardless of whether
the cause of the burn is thermal, chemical, or irradiation.
When treating patients with AGA, we ideally try to remove
50–60 % of the total area of alopecia present. For the average
patient, usually two scalp reductions are required to achieve this
goal, and these can be done either before hair transplantation or,
alternatively, in sequence with transplantation procedures.
2.2 Patient Selection
Scalp reduction surgery is an elective cosmetic procedure.
As with any operative procedure, certain clinical factors
must be taken into account, such as the general health of the
patient, the age of the patient, the degree of alopecia, the
laxity of the scalp, the ultimate objective or goal of the
M.G. Unger and M. Toscani
patient, and the patient’s psychological ability to accept the
scalp reduction procedure and the resulting scar.
The operative procedure is most useful in individuals with
alopecia, Classes III Vertex to VI, according to the classifica-
tion of Norwood and Hamilton. It is important when plan-
ning the operation to take into account the potential for future
hair loss. In general, the greater the degree of laxity in the
scalp tissues, the greater the amount of benefit from the oper-
ation. Only a few patients have so little scalp laxity that scalp
reduction is pointless.
Scalp reductions are most valuable in those who intend to
use all or virtually all of the available donor grafts for as
large and dense coverage as possible. Provided the patient’s
general health is satisfactory, the procedure can be carried
out on patients as young as in their teens or, alternatively,
those who are well beyond middle age. In HIV-positive
patients, in our opinion both hair transplantation and scalp
reduction surgery would be contraindicated because almost
all of these patients will develop significant hair loss at some
stage in the evolution of their disease.
In more recent years, with the advent of follicular micro-
and minigrafts and follicular unit extraction (FUE), some
patients have tended to prefer the appearance of sparse hair
coverage in the mid-scalp and/or crown regions. Most of
these patients do undergo scalp reduction surgery to con-
serve additional donor area for the future, but a few elect not
to have a scalp reduction.
Not all patients can psychologically accept having a por-
tion of their scalp excised. A careful explanation of the oper-
ation itself can often overcome this, but some patients simply
cannot accept the procedure. If the patient can accept the
idea of the operation but refuses to undergo it while awake,
general anesthesia can be arranged. Fortunately, the patients
in each of these groups represent only a small minority.
2.3 Timing of Scalp Reductions
and Sequence of Operations
The scalp reduction may be performed as soon as 1 day
before a hair transplantation session. On the other hand, after
hair transplantation has been carried out an interval of
4 weeks is normally left to allow the body to absorb the
edema. Normally an interval of 3 months or more is left
between subsequent scalp reductions.
In most patients, the procedures of hair transplantation
and scalp reduction surgery are carried out in the following
sequence: two grafting procedures, spaced 6–12 weeks apart,
are performed in the anterior scalp region in a U-shaped pat-
tern. The first scalp reduction is most often carried out
6 weeks after the second hair transplantation procedure, as
well as after subsequent transplanting sessions, which are
usually spaced 3 months apart. In some patients, one or more
scalp reduction procedures are carried out before any hair
Scalp Reduction 557

transplantation. Each sequence of operations has its own

advantages and disadvantages, and usually a patient may
choose to start with either hair transplantation or scalp reduc-
tion surgery. The exception to this are patients who have
early hair loss confined only to the mid-scalp and crown
region, and patients who have relatively advanced hair loss
requiring the lateral fringes to be elevated before a satisfac-
tory anterior hairline can be designed. In each of these two
groups it is strongly recommended that scalp reduction sur-
gery be performed before any hair transplantation.

2.4 Scalp Reduction Patterns

Originally, six basic patterns of scalp reductions were

described as examples of the many possible variations. At
present, the most common patterns used by us are the lateral
pattern or the modified S-shaped pattern. These particular
patterns have the advantage of placing the scar in the crown
region closer to the lateral fringe, which is aesthetically supe-
rior to a midline position. In addition, these patterns allow for
elevation of the posterior hair-bearing scalp, and prevent an
axe-like scar being formed in the occipital region. For the
novice, a midline reduction pattern (Fig. 1) is still the easiest
to perform. However, care should be taken to limit the pattern
to within the area of alopecia posteriorly. Once experience
has been gained with a midline pattern, it is strongly recom-
mended that either the lateral or modified S-pattern be used
for those patients because of the advantages noted above Fig. 1 Midline scalp reduction
(Fig. 2a–c). The Y-shaped pattern and variations of this pat-
tern are most useful when the area of alopecia is pear-shaped,
when there is persistent hair extending anteriorly from the 3 Standard Reduction
occipital region, or when the crown area is to be left untrans-
planted (Fig. 3a–c). The U-shaped pattern can be extremely The standard scalp reduction is characterized by undermining
useful in patients who wish to confine their hair restoration to limited to approximately 10 cm from the incision itself. This
the anterior third or half of the dorsum of their scalp or, alter- undermining may be restricted to the dorsum of the scalp for
natively, in those who require removal of unsightly transplan- certain patterns or, optionally, more than one area including the
tation grafts in the U-shaped region (Fig. 4a–d). The lateral occipital or lateral regions, depending on the location of the
pattern can also be very useful in adjustment procedures, incision. With the major and modified major scalp reductions,
when progressive alopecia has occurred. A variation was pub- all of the aforementioned areas are always undermined with
lished by Alt [7] in 1980. Marzola [10] described a type of each operative procedure. We will use our own modification of
lateral pattern in 1983 that consists of a vertical incision ante- the S-shaped pattern in describing the standard reduction.
riorly in the temple hair, which then extends along the supe-
rior margin of the lateral fringe. The major reduction uses this
type of pattern carried out on each side during the same oper- 3.1 Preoperative Preparation
ation, and for this reason is commonly referred to as a bilat-
eral-lateral scalp reduction, or extensive scalp lifting. We have always performed this surgery as an outpatient pro-
It has always been stressed, and should be emphasized cedure. The patient arrives 1 h prior to the scheduled time,
once again, that even after performing several thousand scalp signs a witnessed consent form, removes all clothing except
reduction operations no one pattern is ideal for all patients. underwear, and is given a hospital gown. While resting in
In general, the pattern should be tailored to meet as many of bed the patient is given either 15 mg of diazepam orally
the goals as possible of the individual patient. Obviously the 30 min prior to surgery, or approximately 10 mg of diaze-
shape of the area of alopecia or the pattern of previous hair pam intravenously immediately before surgery. Meperidine
transplantation must be considered. (Demerol), 50 mg intramuscularly 30 min before the
558
a b
Fig. 2 (a–c) S-shaped scalp reduction and clinical case
operation, is optional for each patient. Photographs are
taken and the pattern of excision is marked on the area of
alopecia. With the S-shaped reduction, the occipital end is
intentionally curved to one side or the other to prevent any
axe-like scar postoperatively, and the posterior end of the
excision is ended within the area of alopecia to avoid a
change in the hair direction posteriorly. For the beginner, the
article by Bosley et al. [6] can be useful in judging the size
of the area to be excised. The surgical goal is always to
remove as much tissue as the laxity of the scalp will safely
allow.
3.2 Anesthesia
A general anesthetic is used only for those patients who can-
not psychologically accept being awake during the opera-
tion or those who are extremely difficult to anesthetize with
M.G. Unger and M. Toscani
local anesthesia. Even when a general anesthetic is used,
local anesthesia with epinephrine should still be used along
the proposed excision lines to minimize blood loss.
The procedure is almost always carried out with local
anesthesia. Usually 20 mL or less of 2 % lidocaine with epi-
nephrine 1:100,000 is our agent of choice. A 30-gauge nee-
dle is used as much as possible, which considerably reduces
the necessary volume and provides an acceptable safety mar-
gin for any toxic reaction.
A field block anesthesia is produced by injecting in a
circle around the circumference of the head inferior to
the expected extent of undermining. A 25-gauge 3-inch
spinal needle is usually used to join initial areas of
anesthesia.
After the field block, 1 % lidocaine with epinephrine
1:100,000 or 1:200,000 can be used for the lines of excision
instead of 2 % lidocaine to further reduce any possibility of
toxic reaction.
Scalp Reduction
a b
Fig. 3 (a–c) Y-shaped scalp reduction and clinical case
3.3 Surgical Technique
The procedure itself is carried out under sterile surgical con-
ditions. The patient is usually placed in a prone position with
a bulky pillow under the chin for comfort. This positioning
gives the greatest exposure to all areas of the scalp region;
however, care must be taken to avoid any blood running
down onto the facial area. On the rare occasion when a gen-
eral anesthetic is used, the patient is usually positioned on
one side or the other.
The surgical area is cleansed with a chlorhexidine solu-
tion (Hibitane), following which the sterile drapes are
applied. Once pallor of the tissue has developed, the opera-
tion is initiated by incising along the lateral side of the area
to be removed. This initial incision usually extends approxi-
mately one-third of the length of the pattern or less, and is
carried down to and through the galea aponeurotica. The
scalpel blade itself should be angled to avoid injury to any
adjacent hair follicles, and in cases of previous hair
transplantation a 2-mm safety margin is normally used.
559
Surgical skin hooks are then used to separate the wound
edges in a non-traumatic fashion as well as for hemostasis,
following which a curved Mayo scissors are used to under-
mine the loose connective tissue between the periosteum and
the galea aponeurotica for 10 cm or more on each side.
Three methods can be used to determine the amount of
redundant scalp tissue that can safely be removed. For the
novice surgeon, the best way to determine this is to overlap
the tissues themselves, placing the lateral portion of the flap
on top of the more medial flap. Subsequently, a series of
horizontal incisions can be made through the lower flap,
stopping at the point where the top flap overlaps. By joining
the horizontal cuts in an anterior to posterior direction, the
redundant tissue will be effectively removed. For the more
experienced surgeon, a skin hook attached to the galea can be
used to pull one flap on top of the other. The staining of the
blood on the underlying flap can then be used as a marked
guide for the amount of tissue to be removed.
The excessive tissue is excised and the hemostasis is com-
pleted. Galeotomies are not usually performed in the scalp
560 M.G. Unger and M. Toscani

a b

Fig. 4 (a–d) U-shaped scalp reduction and clinical case

Scalp Reduction
reduction procedure. Although this technique allows removal
of a larger portion of tissue, it also leads to profuse bleeding
during surgery and higher risk of hematoma formation in the
postoperative period. Moreover, there is a high possibility of
damaging the blood circulation. Although it is generally
agreed that galeotomies are performed in hair-bearing areas
rather than in alopecic ones, it is also true that if that area is
used in the future as a donor site, the number of hairs to graft
will be inferior. We perform galeotomies only on rare occa-
sions, when an excessive quantity of tissue has been inadver-
tently removed.
We advocate closure of the galea with moderate rather
than excessive tension. Under ideal conditions, the edges of
the galea should just meet when bimanual pressure is applied.
If this practice is adhered to, the degree of stretch-back post-
operatively in almost all patients is minimal and not clini-
cally significant.
It is recommended that closure of the wound should
always be carried out in two layers. Initially a fixation suture
is positioned about one-third of the way along the pattern
from the posterior end to adjust for the uneven length on
each side. Once this has been accomplished, the galea apo-
neurotica is sutured using interrupted 2-0 Dexon or Vicryl
sutures placed approximately 1.5 cm apart. Although some
surgeons have advocated the use of a continuous suture for
this layer, we strongly prefer interrupted sutures for the addi-
tional strength they provide for the wound closure. Once the
galea has been closed, the skin edges are approximated with
a 4-0 nylon or Dexon running suture.
At the completion of the surgery, three or four layers of
gauze are placed over the wound, and a piece of 6-inch
stockinette modified to form a cap is applied to hold this
gauze in place. In view of the simplicity of this dressing, the
patient is instructed to remove it himself the next morning.
Although certain authors have advocated an interval of
only 4 weeks between scalp reductions, as previously related,
we recommend an interval of 3 months between repeated
procedures. Often massaging of the scalp for 3 weeks or
more before surgery is recommended after the first scalp
reduction to help free any fibrous adhesions from the initial
operative procedure.
3.4 Stretch-Back
In 1984 Nordstrom [9] coined the term stretch-back to refer
to a stretching of the scalp and an increase in the area of alo-
pecia after a scalp reduction.
He measured this phenomenon and stated that up to one-
half of the benefit of scalp reduction could be lost because of
stretch-back.
Stretch-back was discussed by a panel of experts (includ-
ing the author M.G.U.), which agreed that this phenomenon
561
actually refers to four different situations that are often con-
fused with each other.
• First, in many patients there is progressive MPB between
reductions, not a stretching of the scalp tissue.
• Second, in some patients there is hair loss between scalp
reductions because of vascular changes caused by the
reductions themselves. This phenomenon is usually tem-
porary (telogen effluvium) but in some cases might be
permanent.
• Third, when closure of the galea has been carried out with
more than moderate tension, a widening of the scar can
occur in some patients, which increases the total area of
alopecia.
• Finally, in a few individuals there actually is postopera-
tive stretching of the scalp tissue and an increase in the
area as a result of true stretch-back. This only occurs in
fewer than 2 % of patients when the galea is closed with
moderate tension. Certainly this should not prevent more
than 98 % of patients from benefiting from scalp reduc-
tion surgery.
4 Scalp Reduction with Tissue
Expansion
4.1 Classic or Chronic Tissue Expansion
The concept of tissue expansion prior to excision was popular-
ized by Radovan in 1984 [16]. Initially, the procedure was
used for the expansion of chest tissue as part of postmastec-
tomy reconstruction. Following this, the technique was applied
to the treatment of lesions of the limbs, including giant nevi
and tattoos. In more recent years, several physicians have
applied the principles of tissue expansion to scalp surgery.
To date, tissue expansion of the scalp has most frequently
been carried out to successfully remove large areas of cicatri-
cial alopecia or post-traumatic defects. Recently, the use of
one or more tissue expanders has been applied to the treat-
ment of MPB. This usually occurs in patients who have very
limited laxity and those for whom other types of reductions
provide very little benefit.
During the first operative procedure, the tissue expanders
are placed under the hair-bearing scalp that is to be expanded.
Wound healing is then allowed to occur for 2 weeks, follow-
ing which saline is added progressively (approximately 10 %
of the volume of the expander) to each expander on a weekly
basis. After the first few weeks, saline can be added twice a
week or even more frequently if suitable care is taken.
Once the hair-bearing region has been fully expanded, the
second operative procedure is carried out, during which the
tissue expanders are removed and the scalp tissue is suitably
562
a b
Fig. 5 (a–c) Clinical case of scalp reduction using tissue expanders
advanced and rotated to replace as much of the area of alope-
cia as possible. This second operation is basically carried out
in the same fashion that would be used with tissue expansion
in other parts of the body (Fig. 5a–c).
Chronic tissue expansion does have some inherent diffi-
culties. The expander(s) can be uncomfortable, especially
each time saline is added, and an enlargement of the scalp
region that has been compared with a hydrocephalus defor-
mity is created during the last 6 weeks or so of treatment.
Tissue necrosis, hematoma, infection, nerve dysfunction,
seroma formation, bone resorption, chronic pain, expander
extrusion, and expander malfunction have all been reported.
Overall, however, chronic tissue expansion of the scalp can
be extremely useful for patients with minimal scalp laxity or
for correction of extensive areas of alopecia. Because of the
appearance deformity that is created before improvement is
gained, this method of scalp reduction is often not accepted
by patients who request treatment of MPB.
5 Intraoperative or Acute Tissue
Expansion and the Unger PATE
Procedure
A relatively new technique based on the principle of “tissue
creep” is intraoperative tissue expansion, initially described
by Gibson in 1977 [17]. Much of the pioneering work in this
area has been done by Sasaki [18]. In this technique a tissue
expander is inserted in a pocket at the time of surgery and
then inflated and deflated for several stress-load cycles dur-
ing the operation, rather than being left in place for several
weeks. During each cycle the expander is inflated with saline
for 2–3 min, followed by a deflated rest period of similar
duration. Usually three or more cycles are carried out during
the operation, and each time the expander can be inflated a
little more. The reported average “gain” in tissue varies with
the anatomic location (Fig. 6a, b).
In 1995 the first paper describing the prolonged acute tis-
sue expansion (PATE) procedure was published by Unger
M.G. Unger and M. Toscani
c
[15]. This technique utilized cyclic loading of a tissue
expander, intraoperatively, for an extended period of time
(60 min or more) combined with precise pressure monitoring
of the pressure within the expander. As a result of this PATE,
a significantly larger amount of redundant scalp tissue could
be removed in the scalp reduction procedure that followed
the tissue expansion. The results of the first 75 procedures
using this technique were published in 1997. Since then, we
have carried out several hundreds of these operations. If the
surgeon has the knowledge and skill to incorporate PATE
into his scalp reduction procedures, a marked improvement
in scalp reduction results will be achieved.
6 Conclusions
Scalp reductions have now been carried out for more than
30 years. Modifications and improvements over the years
have significantly contributed to the results, and the concept
of scalp reduction itself has now gained widespread recogni-
tion and acceptance.
Although scalp reduction has been used by itself to decrease
the area of alopecia, it is most commonly used in combination
with hair transplantation to remove most of the area of alope-
cia of the mid-scalp and crown areas or, alternatively, to assist
in the repair of previous unsatisfactory hair transplantation.
No single pattern for scalp reduction is ideal for all patients,
and the surgeon should have the talent and desire to modify
each operation to achieve the goals of each individual patient.
Attempts to remove the maximum amount of scalp tissue in
each patient could conceivably lead to severe complications,
such as wound dehiscence and permanent hair loss. In our
experience (well over 10,000 scalp reduction operations to
date), it is always much wiser to take a little bit less than a little
bit more. When the procedure is carried out by a competent
physician, the likelihood of complications is far less than with
almost all other cosmetic surgery operations. The resulting
improvement in appearance and patient gratification from scalp
reduction procedures continues to be extremely rewarding.
Scalp Reduction 563

a b

Fig. 6 (a, b) Clinical case of scalp reduction using intraoperative acute tissue expansion

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7 Advantages suration); concept nouveau dans le traite-ment chirurgical de la cal-
vitie. Rev Chir Esthet Long Fr 4:5–10
• Increase in the available hair-bearing surface 3. Blanchard G, Blanchard B (1984) Proposition d’une approche
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• Conservation of a homogeneous and slightly reduced hair surale. Ann Chir Plast Esthet 29:152–161
density 4. Stough DB 3rd (1979) Innovative adjuncts in hair transplantation.
• Possibility to harvest larger flaps that are easier to suture Cutis 24(2):173–175, 177
• Improvement in the vascularization of some flaps 5. Unger MG, Unger WP (1978) Management of alopecia of the scalp
by a combination of excision and transplantation. J Dermatol Surg
Oncol 4:670–672
6. Bosley LL, Hope CR, Montroy RE, Staub P (1982) Reduction of
8 Disadvantages male pattern baldness in multiple stages: a retrospective study.
J Dermatol Surg Oncol 6:498–503
7. Alt TH (1980) Scalp reduction as an adjunct to hair transplantation,
• Need for at least two (usually three) surgical sessions review of relevant literature, presentation of an improved technique.
• General anesthesia J Dermatol Surg Oncol 6:1011–1018
• Pain following each expansion 8. Norwood OT, Shiell RC (1984) Hair transplant surgery. Charles
• Creation of a (temporary) deformity that is visible to oth- C. Thomas, Springfield
9. Nordstrom REA (1984) Scalp kinetics in multiple excisions for cor-
ers and sometimes badly tolerated by the patient or his rection of male pattern baldness. J Dermatol Surg Oncol 10:991–995
family 10. Marzola M (1984) An alternative hair replacement method. In:
• Need for the patient to attend sessions for filling of the Norwood OT (ed) Hair transplant surgery. Charles C. Thomas,
expander. Springfield, pp 315–324
11. Marzola M (1988) Combination of lateral scalp reductions and pre-
• Often prolonged time off work or “social isolation” auricular flaps: hair replacement without punch grafts. In: Unger W,
• Possible complications (up to 20 %) that may sometimes Nordstrom R (eds) Hair transplantation, 2nd edn. Marcel Dekker,
require emergency surgical operations: New York, pp 691–705
– Hematoma 12. Brandy DA (1986) A new surgical approach for the treatment of
extensive baldness. Am J Cosmet Surg 3:19–25
– Infection 13. Frechet P (1985) How to avoid the principal complication of scalp
– Wound dehiscence, skin necrosis reduction in the management of extensive alopecia. J Dermatol
– Expander exposure Surg Oncol 11:637–640
– Alopecia by excessive tension 14. Frechet P (1993) Scalp extension. Dermatol Surg Oncol 19:616–622
15. Unger WP, Nordstrom R (1995) Hair transplantation. Marcel
Dekker, New York, pp 1–830
16. Radovan C (1984) Tissue expansion in soft tissue reconstruction.
Plast Reconstr Surg 74:482
17. Gibson T (1977) The physical properties of skin. In: Converse JM
References (ed) Reconstructive plastic surgery, vol 1. WB Saunders, Philadelphia,
pp 70–77
1. Sparkuhl K (1978) Scalp reduction: serial excision of the scalp with 18. Sasaki GH (1987) Intraoperative sustained limited expansion
flap advancement. Presented at the International Hair Transplant (ISLE) as an immediate reconstructive technique. Clin Plast Surg
symposium, Lucerne, 4 Feb 1978 14:563–573
 Skin Extenders

Ciro De Sio and Marco Toscani

1 Introduction
The concept of skin extension was introduced by Patrick
Frechet [2] in the early 1990s and was created as an evolution
of skin expansion [9–11], with the intent to maintain its
advantages and reduce its negative side effects. The usual
indication is androgenetic alopecia (AGA), located at the ver-
tex in patients with stabilized baldness. In the case of exten-
sive baldness, it can be complementary to autografting.
Stretching of the scalp has been made possible by the
extender, an elastic device presented for the first time by
Frechet himself in Dallas, Texas, USA, during the First
World Congress of the International Society of Hair
Restoration Surgery in 1993.
2 How the Extender Works
The extender is a tool consisting of a silicone foil, with a
titanium strip on each end; each strip has a series of small
hooks made of the same metal (Fig. 1). Because of its elastic-
ity, the silicone, once extended, tends to return to its initial
state. If one of the two ends of the strip is hooked to the
extremity of a hair-bearing area, this area can be stretched
and its size increased so that it covers the bald areas. Over
the years there has been a continuous evolution in the quest
to enhance the performance of this device, the latest genera-
tion presenting numerous advantages over the original.
Owing to modern technology it has been possible to design
a silicone elastomer that can extend itself up to 200 % beyond
its initial size, thus reducing the distance at rest between the two
series of hooks. This feature has allowed reduction in the size of
the instrument, making it easier for the surgeon to position it,
and greater effectiveness enabling it to remain in place for up to
2 months, thus reducing the number of surgical “steps.”
It is placed under the galea, and therefore is not visible
and does not deform the scalp, unlike skin expanders which,
for these reasons, are not always accepted by patients who
choose to undergo surgery for aesthetic purposes.
The scalp reduction achieved with the extender should be
completed with three transposition flaps in the occipital region,
according to an original scheme designed by Frechet [6–8]. In
this way the unaesthetic residual median scar can be hidden,
being transformed into a prevalently horizontal sinuous scar.
Other prototypes positioned outside the scalp have been
introduced, which although they have the advantage of
adjustable force of traction not have the typical characteris-
tics of Frechet’s extensor, which is practically invisible and
does not come into contact with the external scalp, thus
reducing the risk of infection. For the same reasons men-
tioned in relation to the expander, external extenders have
not garnered many supporters.

C. De Sio, MD (*)
U.O.C. di Chirurgia Plastica, Istituto Dermopatico
dell’Immacolata (IDI), Rome, Italy
e-mail: c.desio@idi.it
M. Toscani, MD
Ricercatore Universitario di Chirurgia Plastica, Dipartimento
di Chirurgia, Università di Roma “Sapienza”, Rome, Italy Fig. 1 Skin extenders

© Springer Berlin Heidelberg 2016 565

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_40
566
3 Surgical Technique
The technique includes two surgical sessions:
1. Scalp reduction and positioning of the extensor
2. Removal of the extender and completion of the three flaps
3.1 Scalp Reduction and Positioning
of the Extender
The aim is to remove as much baldness as possible by using the
natural elasticity of the scalp, by correctly inserting the extender
and suturing the surgery breach without producing tension.
The indications for scalp reduction with Frechet’s [4]
extender are almost identical to those of the skin expanders:
• AGA concerning the vertex
• In the case of extensive baldness, complementary to
autografting
• Alopecic scars caused by traumas [13]
• Giant moles
On switching concepts from increased volume to disten-
sion, the extender has several advantages over the expander:
• Better management of the patient, who does not need to
return to the surgeon’s office to recharge the device
• The extender does not deform the scalp, nor is it visible,
so does not oblige patients to interrupt their usual work-
ing activities, nor are patients obliged to change their
social relations
• The gain of hair-bearing scalp is faster, and it is possible
to proceed to the second operating session after 45 days
3.1.1 Choosing the Patient
Patients with AGA, in a good state of health confirmed by an
appropriate preoperative check-up, may be selected.
Patients who smoke, are in poor general health condition,
or are affected by systemic diseases (diabetes, hypertension,
etc.) are not eligible. The ideal patient must have the follow-
ing characteristics:
• Age of at least 27–30 years: a very young patient in the
middle of the balding phase is not appropriate in these
cases, because it is not possible to foresee the final distri-
bution his hair-bearing scalp. This type of surgery, in
these conditions, is not recommended because the scars
will remain evident in the event of further hair loss
C. De Sio and M. Toscani
• Stabilized baldness around the vertex and on the top of
the head
The presence of a tuft of hair, more or less thick in the
frontal region, is useful because it hides the frontal part of
the median scar (see below).
If, instead, the forehead is completely bald, one or
more subsequent autograft sessions are recommended,
with the reconstruction of a new frontal line: in this case,
the scar should end a few centimeters away from the fron-
tal line.
In the presence of extensive baldness, involving the fore-
head and the vertex [1], a program should be planned with
the patient, ideally including:
• One or more scalp reductions with the aid of the
extender
• One or more autograft sessions in the residual frontal
region
The advantage consists in the fact that the size of the bald
area to be grafted is smaller after the use of the extender: this
strategy allows the surgeon to make most use of the limited
amount of hair in the donor area.
For an optimal timing in these cases, we recommend
performing first one or more scalp reductions with the
extender, then one or more autografting sessions. However,
this choice is not compulsory, because in our practice we
have also operated on patients with one or more previous
autograft sessions.
• The size of the bald area to be removed must fall within
reasonable limits, to avoid any exasperation of the tech-
nique or to give rise to false expectations by the patient (in
our practice, we have been able to eliminate up to 15 cm
of bald scalp without any problem) (Fig. 2)
• Highly motivated in undergoing the surgery
When a patient accepts to undergo this type of surgery, he
should be well aware of the possible side effects. First, the
patient must know that he will suffer pain for the first 12 h,
although this symptom will then change to an acceptable
sense of tension. A well-proven analgesic usually can mini-
mize this pain, and if patients are well informed and fully
aware, they can easily overcome these problems (Fig. 3).
This technique includes several surgery sessions that cannot
be interrupted.
3.1.2 Loose Scalp
Preoperative massage can facilitate the surgery, because it
makes the scalp looser.
Skin Extenders 567

Fig. 2 (a) Preoperative area a b

to be covered is 15 cm.
(b) Postoperative

Time of
% maximum pain
100 believe that the size of the extender offering a maximum
90 16 22 extension of 150 mm is appropriate in most cases.
80 Pain curve
70 3.1.5 Preoperative Drawing
60 It is essential to plan exactly where the device will be posi-
50 tioned, because at the end of the procedure, during the sec-
40 ond surgical session, the entire area between the two sets of
30 hooks must be removed, otherwise this area will expand and
20 Recovery contribute to the stretch-back phenomenon.
10 Before starting the infiltration of local anesthetics, it is
0 better clean the skin with an alcoholic solution and draw
Time 12 24 36 48 60 72 96 120 144 168
Days 1 2 3 4 5 6 7 the landmarks with a skin marker, outlining where
Intervention the extender will be positioned and the area to be
undermined.
Fig. 3 Pain level over the first 12 hours following surgery Remember that if the first surgical session is correctly
planned, this will affect the success of the entire
procedure.
3.1.3 Scars
Scars on the scalp do not absolutely compromise the oper- 3.1.6 Key Points
ation: in fact, the success of the operation depends on
their location. The scars located in temporal-parietal • The first point to drawn is the V (vertex): this is the pro-
region can hamper and/or limit the relaxation of the scalp; jection on the scalp of the conjunction of two straight
instead there should be no scars in the area where the lines, passing through the occipital and sagittal planes.
three flaps will be drawn. The scar on the back of the The V point guides the surgical procedure with regard to
head, left by previous harvesting of hair grafts, is not usu- both the positioning of the extensor and the subsequent
ally a problem as long as it does not fall inside the draw- drawing of the three flaps. In fact, all the measurements
ing of the third flap. However, one can expect to encounter originate from the V point (Fig. 4).
some major difficulty in suturing the incision breach cau- • Draw a diagonal line passing through V, indicating the
dally to the third flap. occipital limit of where the extender must be placed
(Fig. 5).
3.1.4 Choosing the Size of the Extender
The latest generation of the extender is available in two sizes, Please note: the extender loses strength if it is placed
depending on the size of the bald area to be removed. We excessively above or below this line.
568 C. De Sio and M. Toscani

Vertex “V” Frontal limit of the incision

• Should offer a comfortable access for the extender

• Guides both the first and second step
• From “V” initiate all the measurements
of the plan
Fig. 4 V-point: junction of the occipital and sagittal planes
• Do not go beyond the frontal hairline
Fig. 6 Patients with frontal alopecia. Skin incision frontally to the ver-
tex should allow for easy access to insert the extender

• Draw the frontal limit of the median incision.

The transversal line passing through “V”
• In patients who also have frontal alopecia, we recommend
to not go beyond the ideal frontal line one wants to restore
or, better still, to stop 1–2 cm more caudally to make sure
the scar will not be visible. The folds that may appear on
the scalp will initially be evident but will gradually disap-
pear, but if necessary can be corrected later. In any case,
the skin incision frontally to the vertex should ensure a
large and comfortable access for the insertion of the

V extender (Fig. 6).

• Draw the occipital limit of the median incision, which
must be at a distance of maximum 7 cm from the Vertex:
if this distance is not respected, one runs the risk of alter-
ing the planning of the three flaps in the next surgical ses-
sion (Fig. 7).
• Starting from the diagonal line, on both sides, mark the
points where the hooks must be inserted on the edges of
the bald area, no further than 0.5 cm into the hair-bearing
The graph shows where to position the extender scalp (Fig. 8).

Lifting of the eyebrow

• If more caudally
3.1.7 The Authors’ Surgical Technique
Dispersion of force
This surgery must be performed in an appropriate operating
• If more frontally Makes little difference on room in the presence of an anesthetist. Fortunately, cases of
the occipital region emergency in our practice have been rare but they can occur,
almost always including attacks of anxiety. On the other
Fig. 5 Transverse line through the V-point indicated the occipital limit
where the extender can be place hand, one must be careful to avoid an overdose of local
Skin Extenders 569

Occipital limit of the incision
anesthetics. The anesthetist, in addition to dealing with unex-
pected complications, can facilitate infiltration by performing
an adequate sedation, which also allows reduction in the
doses of local anesthetics.
Prepare an anesthetic mixture (2 % lidocaine with a
1:100,000 dilution of adrenaline), which is injected in small
and regular shots over the entire surface to be treated: since

v
extensive undermining will be required, it is better to infil-
trate both the median area and laterally, up to the retroauricu-
lar sulcus, and frontally, up to the frontal recesses.
Postoperatively, prescribe an appropriate antibiotic and
corticosteroid therapy to reduce edema.
With regard to pain, which is one of the main dissuasive
factors of this method, we have developed a specific analge-
sic therapy, such that this type of surgery can be considered
just as any other procedure commonly performed in plastic
surgery.
With the patient in a semi-sitting position on the operation
7 cm away from “V” bed, with the marks already drawn and after the anesthesiol-
Fig. 7 Occipital limit of the median incision is 7 cm from the ogist has administered an appropriate sedation, we infiltrate
vertex (V) the scalp with the aforementioned mixture, cut along the
median line with a no. 10 scalpel blade, and perform a broad
subgaleal undermining, which:
Exact projection of the extender lodging Bilaterally reaches the retroauricular sulcus
Please note: the superficial temporal artery runs along the
anterior margin of the auricle.
Frontally, follows an ideal line joining the front edge of
the incision to the anterior margin of the auricle

• Toward the back, proceeds only along the median line, to

avoid damaging the two occipital peduncles

The undermining is performed along a practically avascu-

0.5
V We can increase this size by means of a forced intraopera-
• On the transversal line
• With hooks no more than 0.5 cm away from the
limit of the bald area to reduce stretch-back
Fig. 8 Marking for the extenders in the bald area not to exceed 0.5 cm
into the hair-bearing scalp
lar plane, and in fact we usually perform homeostasis with an
electroscalpel only along the incision line.
We extensively mobilize the scalp and remove a lozenge of
bald area, the size of which depends on the laxity of the under-
mined scalp: in general, at the vertex it will be at least 3 cm.
tive extension with a multiple hook. To perform this
maneuver, we hook the device to the galea of the two sides,
and exercise a forced and repeated traction on at least three
points per side. These actions, on the one hand, increase by
about 25 % the removable part of bald area, and on the other
increase the degree of postoperative pain, an unpleasant
experience for the patient. Therefore it is better to limit these
actions only to selected cases (Fig. 9).
After removing the portion of bald area, according to the
degree of skin laxity, we seize one of the two metal bars with
a needle holder (Fig. 10), anchor the hooks to the galea on
one side of the incision according to the preoperative
570
Fig. 9 Instrumentation used to undermine scalp
Fig. 10 Use of needle holder to pick up extender
drawing, and with a specific spatula-shaped instrument
extend the extensor and hook it onto the other side, as we
initially did on the opposite side (Fig. 11).
The traction force exerted by the device must be enough
to stretch the galea without tearing it, and the two margins
are sutured with no closing tension.
The patient does not need medication and can be sent
home with a therapy regimen including analgesics, antibiot-
ics, and corticosteroids.
C. De Sio and M. Toscani
3.1.8 Factors that Reduce the Effectiveness
of the Extender
• Hematoma
• Undermining is performed on the subgaleal level, which
is an avascular area: the risk of a hematoma increases
following galeotomies, which should therefore be
avoided.
• Adhesions between the galea and the periosteum, second-
ary to:
– Intraoperative bleeding
– Local inflammatory reactions
• Previous scars on the scalp
3.1.9 Factors that Increase the Effectiveness
of the Extender
• Parentally administered long-acting corticosteroids, as
they reduce adhesions
• Preoperative massages of the scalp
• Correct positioning of the extender
• Loose scalp
• Extender inserted for 45 days
Please note: avoid administering corticosteroids locally
because they increase the risk of infection.
• Intraoperative extension with multiple hooks
• Double extender
The last two maneuvers increase the incidence of postop-
erative pain, so they must be performed only in patients who
both require them and are particularly motivated.
3.1.10 Side Effects
• Pain in the postoperative period which, with adequate
analgesic therapy, decreases from the next day until it
disappears, without interfering with the patient’s quality
of life
• Seroma
• Hypoparesthesia of the occipital region
• Front and eyelid edema with lasting eyelid pigmentation:
infrequent, temporary, but annoying
3.1.11 Complications
The most serious complication is infection with the conse-
quent need to remove the device, a rare but possible event
Skin Extenders
Fig. 11 Placement of spatula-shaped instrument used to push the extender and engage the hooks. (a) Schematic drawing. (b) Intra operative
photograph
3.2 Removal of the Extender
and Correction of the Median Scar
Through Three Transposition Limbs
The second operation, 45–60 days after the first session, con-
sists in the removal of the now ineffective device, because of
its return to original status, and the removal of the planned
bald tissue, which will be replaced by hair-bearing scalp,
gained by the extender during its positioning at the bottom of
the galea [3–5, 12].
The method is completed by the preparation of three
transposition limbs. This surgical procedure is required for
three reasons:
1. To remove more bald scalp
2. To avoid the unaesthetic median scar in the occipital
region
3. To naturally direct hair growth downward to mask the
scars that are no longer vertical, but horizontal (Fig. 12)
3.2.1 Preoperative Drawing
Marking is the basis for the success of the operation, hence
the need for an accurate project that remains visible until
the end. The ideal would be to perform the operation on
a shaved head, but in general patients do not like this
because postoperatively they do not want to show signs of
their surgery. Therefore, to avoid the possibility that surgi-
cal maneuvers erase the preoperative drawings, we mark
the landmarks with colored thread to create a “track” of
the flap perimeters.
571
To be even more accurate, we use a compass with two
metal extremities and a central ring.
3.2.2 Drawing of the Three Flaps (Fig. 13)
The diagram shows the three limbs and the median gap, fol-
lowing the removal of the bald area.
The central bald area (shown in green, Fig. 14)
First flap (shown in yellow, Fig. 15)
Second flap (shown in blue, Fig. 16)
Third flap (shown in pink, Fig. 17)
3.2.3 Authors’ Technique
After sedation by the anesthetist and after administering
local anesthesia, we cut along the previous scar, take the
extender, grasp it with a needle holder at one of the two metal
bars, and, with a rotating movement, remove the hooks from
the galea, first on one side, then the other.
We widely undermine the subgaleal plain, remove the
median bald area, and proceed with the preparation of the
three flaps, positioning the patient half-seated for the first
two flaps and lying on the left side for the third flap.
Having cut out and placed the first two flaps, we do not
immediately remove all the planned bald area, but remove
the bald area only after preparing and positioning the third
flap; a portion of this tissue might be useful to suture the final
gap with less tension.
The incisions are parallel to the follicles to prevent their
sacrifice, and must also include the galea to avoid compro-
mising the vitality of the flaps.
The patient can be discharged without any dressing, with
antibiotics and analgesics to be taken at home.
572
Fig. 12 (a) Preoperative. (b) Intraoperative planning. (c) Median scar. (d) Directing the hair growth downward to hide the scars that are now hori-
zontal. (e) Final result
3.2.4 Side Effects
• The scalp, stretched by the extensor in the bitemporal
region, ultimately presents moderate thinning, but none of
the patients have ever noticed this feature, nor have they
ever complained about it
• Telogenic hair loss, especially at the extremity of the sec-
ond and third flap: this is generally due to unsound plan-
ning of the operation, with consequent suture of the limbs
under tension
C. De Sio and M. Toscani
• Hypoparesthesia of the occipital region that can last as
long as many months
• Front and eyelid edema with long-lasting eyelid pigmen-
tation, an unpleasant occurrence for both the patient and
surgeon
3.2.5 Complications
Marginal or total necrosis of the flaps is rare but possible,
resulting from unsound planning of the operation, and is
Skin Extenders 573

Fig. 13 Schematic of the three F

flaps

F Frontal margin of the median

scar
V Vertex on the median scar
V’ V’’
V’–V” Vertex after removal of the
A” V A central bald area
O Occipital margin of the 3rd flap
O’ Lateral right margin of the 3rd flap,
B B” so that B’−O=B’−O’
A–B–C Lateral margin of the basis of each flap:
A = 1st flap
C” B = 2nd flap
A’ C C = 3rd flap
A’–B’–C’ Apex of each flap
A’ = 1st flap
B’ = 2nd flap
C’ = 3rd flap
A” Left lateral margin of the central bald area,
will host Apex A’ of the 1st flap
B’ B Median margin of the basis
C’ O’ of the 2nd flap B–B”
C” Median margin of the basis
of the 3rd flap C–C”

Fig. 14 Central bald area F

(shown in green)

F Frontal margin
B’ Occipital margin
V’ V” V Vertex 7 cm from B’
Trace a transversal line passing through V,
A” V
which also indicates the occipital limit
2 cm
where the extender will be inserted.
The V–F distance is variable.
The width of the gap in the frontal region may
3 cm
vary, at the Vertex it has to be 1 cm, in the
occipital region it has to be 3 cm.
7 cm

A” 2 cm away from V’
V’ 0.5 cm away from V on the left side of the
median line
V” 0.5 cm away from V on the right side of the
median line
The line that joins A” to V’ is very arched
because it will host the 1st flap

B’

Basis
(on the transversal line passing through the Vertex)
V’ V” A–V” of 2 cm
A” A
V 2 cm
Apex A’ 4 cm away from A

The line that joins A to A’

m

will have a specular curved pattern

4c

on the semicircle V’–A”

A’ Point A’ will join with A” adapting itself to the drawing

Fig. 15 First flap (shown in B’

yellow)
574 C. De Sio and M. Toscani

Fig. 16 Second flap (shown in

blue) F

Basis (2 cm away from the transversal line passing

through the Vertex) B − B” = 2.8 cm
V A

2 cm Apex C’–B’ = 2.8 cm (like the basis)

B 2,8 cm B”
Point B’ will fit into A

2,8 cm
C’ B’

Fig. 17 Third flap (shown in F

pink)
Basis (caudally to the transversal line passing
through the Vertex and not parallel to it)
C–C” = 3 cm
C = 4 cm away from the transversal line passing
V through the Vertex
C” = 3 cm from the transversal line passing
through the Vertex on the right lateral margin
B 3 cm
of the 1st flap where the apex starts to curve
1,8 cm 4 cm Apex: C’–B’ = 2.8 cm corresponding to the apex
C” of the 2nd flap
3c
m O and O’ indicate the two landmarks necessary
C
to outline the distal third of the 3rd flap
Each are positioned 2 cm away from B’

Attention:
C’ 2,8 cm B’
2 cm The margin C–O is slightly arched, almost a
O’ straight line
2 cm
The tract O–C’ is instead very arched
O
Apex C’ will fit into B

aggravated by the presence of risk factors such as cigarette

smoking. In general, the scalp is very well supplied with blood
vessels and tolerates precarious situations well. In any event,
scars can be improved at a later time with good aesthetic results.
Diastasis of the scars, particularly of the median scar that
starts from the vertex, and of the third flap on its caudal side,
is possible. With regard to the diastasis of the median scar,
the most frequent cause concerns the incomplete removal of
the entire surface between the two series of hooks, an area
that is compressed during the action of the extender and
which, if not removed, extends itself. To overcome this
inconvenience, in addition to the correct surgical technique
we find it useful to place some robust nylon stitches to fix
the galea to the periosteum. We put these stitches away from
the breach so as to position a second series of smaller-sized
stitches nearer to the edges. The skin can eventually be
sutured with a colored non-absorbable thread, even 5-0, so
that the scalp remains stable. To reduce tension on the third
flap, in addition to the classical maneuver of fixing the
occipital scalp to deeper levels we have introduced a modi-
Fig. 18 Personal modification to balance the two sides of the breach
fication to the original technique. To match the size of the
Skin Extenders
two sides of the breach, we decided to shorten the occipital
side by creating a “dog ear,” which we initially fixed but
then neglected, as it did not give rise to any aesthetic incon-
venience; on the contrary, in the event of autografting, it
offered an additional harvesting area (Fig. 18).
Difficulty suturing the breach between the third flap and
the cephalic side of the occipital scalp may arise because of
either unsound planning or the presence of a previous
transplant scar. To solve this problem, we prepared a fourth
flap or removed a minor portion of median bald area, or
placed a temporary skin autograft. Once we regained elastic-
ity, we improved the scars and eliminated the graft: in these
cases, the major difficulty was to have the patient accept this
possibility. This scenario shows how important it is to have a
clear and correct informed consent, which has to be read and
signed by the patient a few days before the operation.
Other complications include: protrusion of the extender
(rare), owing to inaccurate positioning of the device; infection;
and fistula along the scar from a tuft of hair trapped in the suture.
References
1. Anderson RD (1993) The expanded “BAT” flap for treatment of
male pattern baldness. Ann Plast Surg 31:385–391
2. De Sio C. (2002) Frechet’s extender in reconstructive surgery pre-
sented at the 5th Annual Congress ESHRS. London, England, 6–9
June 2002
575
3. De Sio C (2004) Chapter 20 b. Scalp extension and 3-flap slot cor-
rection. In: Unger WP, Shapiro R (eds) Tips for novices in hair
transplantation, vol 4. M. Dekker, New York, pp 785–793
4. De Sio C (2008) Chapter 58. Slot occipital correction with three
transposition flaps. In: Robbins R (ed) Textbook of dermatologic
surgery, vol 2. Piccin, Padova, pp 831–834
5. De Sio C (2008) Chapter 58. Slot occipital correction with three
transposition flaps. In: Rusciani L, Robins P (eds) Textbook of der-
matologic surgery, vol 2. Piccin, Padova, p 833
6. Frechet P (1996) Interêt d’associer Extension immediate et
Extension prolongée dans le traitment des calvities étendues. Revue
de Chirurgie Esthetique XXI(85):3–14
7. Frechet P. (1996). Management of extensive alopecia by scalp
extension with occipital slot correction. In: Face, vol 4, no 3. Kugler
Publications, Amsterdam, New York, pp 125–137
8. Frechet P (2007) Minimal scars for scalp surgery. Dermatol Surg
33(1):45–55, discussion 55–56
9. Hazan A (1999) Nouvelle approche pour les réductions de tonsure.
Méd Esth Chir Derm XXVI:157–161
10. Magalon G, Aubert JP, Bardot J, Paulhe P (1992) Tissue expansion.
Imprimerie Lamy, Marseille, France, pp 55–77
11. Manders EK, Graham WP 3rd (1984) Alopecia reduction by scalp
expansion. J Dermatol Surg Oncol 10:967–969
12. Nordström RE, Raposio E (1999) Scalp extension–a quantitative
study. Dermatol Surg 25(1):30–33
13. Rosati P (1995) Extensive head burns corrected by scalp extension.
Dermatol Surg 21(8):728–730
 The Suture of Nordstrom
Manfredi Greco, Tiziana Vitagliano,
and Rolf E.A. Nordstrom
The extensive loss of tissue, especially if located in certain
parts of the body, often provokes serious problems for their
reconstruction. The use of skin expanders where the skin is
less elastic, such as at the level of the scalp or limbs, allows
the use of quantities of similar skin sufficient enough to
reconstruct the defect.
This method, known as tissue expansion, was introduced
in surgical practice at the end of the 1950s when an article on
the post-traumatic reconstruction of an ear using a device
filled with air passed through an external tube was published
in Plastic and Reconstructive Surgery [1]. Tissue expanders
subsequently became popular, leading to the creation of
devices that exploit the elastic properties of the skin through
stretching by a tank filled progressively with saline. There
are currently hundreds of different products on the market
with different shapes and sizes, all consisting of a tank in sili-
cone and a connecting tube that connects it to a filling valve,
made in such a way that the injected solution cannot flow
back. Depending on the shape they can be divided into rect-
angular, round, or crescent, and depending on the clinical
expansion they can be spread in the same way over the entire
surface of the device or in a different way to achieve stronger
expansion at a certain point in preference to another. These
devices, in particular those with differential expansion, are
successfully used in the treatment of baldness for their abil-
ity to create sufficient amounts of skin for the reconstruction
of an alopecic area.
M. Greco, MD (*)
Dipartimento di Medicina Sperimentale e Clinica,
Università “Magna Graecia” di Catanzaro, Catanzaro, Italy
e-mail: manfredigreco@unicz.it
T. Vitagliano, MD
U.O.C. di Chirurgia Plastica Ricostruttiva ed Estetica,
Fondazione Oncologica “T. Campanella”,
Polo Oncologico di Eccellenza “Germaneto”, Catanzaro, Italy
R.E.A. Nordstrom, MD, PhD
Chief, The Nordstrom Hospital of Plastic Surgery, Helsinki,
Finland
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_41
The introduction in surgical practice of tissue expanders
has thus increased the possibility of scalp reduction or,
indeed, any approach to replacing extensive losses of tissue.
However, there is some discomfort for the patient. Tissue
expanders require several sessions of filling to achieve the
desired expansion. In addition, they require surgical inter-
vention for their removal and confer a temporary deformity
almost never accepted by the patient, and the small donor
sites can hardly ever be expanded. The high cost of these
devices should not be underestimated. The Frechet extender,
widely used, determines a stretching force that reaches
675 g, whereas as shown by many studies the ideal force to
be applied to a wound subjected to tension should range
between 500 and 1,500 g.
Reduction of the scalp through serial excisions of the skin
is an alternative to treating baldness with tissue expanders.
This method has been used since the 1970s, when the
Blanchard brothers described the success of this technique,
although it harbors certain limitations such as the need for
repeated interventions to complete the areas of alopecia and
the excessive tension that acts on the sides of the wound. These
factors can often lead to “stretch-back” and reappearance of
the alopecia area, and enlargement of the scar over time.
All of these problems have led to the development of a
special and innovative elastic suture, the suture of Nordstrom.
Proposed in 2001 by Nordstrom, this silicone suture, initially
designed to overcome the difficulties related to scalp reduc-
tion and sample areas in hair transplantation (Figs. 1 and 2),
has been widely used in various parts of the body. The start-
ing point of Nordstrom’s research was to find a device that
could reduce to a minimum stretch-back, the major compli-
cation to occur during surgery of the scalp.
The theoretical basis of the development of Nordstrom’s
method was evaluation of the tension that occurs along the
edge of the suture during both the early stages of healing and
the later stages of scar contracture. From this assumption
came the idea of creating a suitable suture that is
hyperextensible, in contrast to suture strings that cannot resist
or adapt and thus contribute to a failure of the suture itself.
577
578
a b
Fig. 1 Use of the suture in silicone for the reduction of areas of alopecia of the scalp. (a) Preoperative marking – area of alopecia to be excised.
(b) Postoperative following use of silicone suture
Fig. 2 Sutures in polymer silicone in different diameters and with dif-
ferent needles
The suture of Nordstrom is a device made up of silicone
polymers, in different diameters and with different-sized
needles based on the part to be treated; it is so elastic that it
can be stretched such that its resting length can even reach
400–500 % of its dimensions, exemplifying high-tension
strength.
The suture can be removed later as needed or left in place,
as it is colonized by connective cells, transforming the string
into a “natural ligament” which, together with fibrotic colo-
nization, stabilizes the results in time. The string is not pal-
pable, since it has the same consistency as the subcutaneous
tissue and also has excellent biocompatibility.
The forces that normally act on the wound edges are
reduced by the suture, absorbing the vector forces responsi-
ble for the enlargement of the scar itself.
In a study by Nordstrom et al. [2], 10 patients with alope-
cia were operated on for scalp reduction and subsequent
insertion of the suture in the galea plane, anchoring it to the
two sides of the surgical breach and sliding it between the
M. Greco et al.
two ends. A measurement of the reduction of the scalp
achieved was performed immediately after surgery and com-
pared with data from other studies on scalp reduction. The
results obtained showed an immediate increase in the amount
of removable tissue in comparison with the control group,
highlighting, therefore, how wider wounds can be treated
using such a device, allowing a suitable advancement of the
tissues, a simplification of the excisions, and a lower proba-
bility of serious scars. In particular, an estimated benefit of
148 % more than the standard single suture was made on
comparison with data obtained from other tissue extenders.
The approach of the edges resulting from the Nordstrom
suture enables definitive closure of the wound with normal
sutures, avoiding the stretching of the edges typical of the
sutures themselves in these locations. This device has greatly
increased the chances of scalp reduction, whereby the ana-
tomic features do not always allow an appropriate distribu-
tion of the tissues. Fan and Wang [3], following Nordstrom’s
invitation, have broadened the location of action of the
suture, using it for excision of scars from previous burns,
observing how the suture first allows avoidance of all large
skin detachments, necessary in these cases to reduce the
enlargement of the scar (which reduces the blood supply to
the skin and subcutaneous tissue and increases the risk of
necrosis), and then prevents the formation of pathologic
scars (Figs. 3, 4, 5, and 6).
The results obtained by Nordstrom have shown how the
silicone string gives similar or better results than the skin
expanders, while exceeding the limitations of the latter. In
fact, the high cost of the expanders, the more complex surgi-
cal techniques, and the aesthetic or functional impediment to
social relations are some of the features that in many situa-
tions limit the use of such devices (Fig. 7).
In conclusion, the Nordstrom suture can be considered a
safe, simple, effective, and economical device that ensures
the extension of the tissue and avoids the enlargement and
stretch-back of scars where there is considerable tension.
The Suture of Nordstrom 579

a b

c d

Fig. 3 Technique for the use the Nordstrom suture. (a) Anchoring to a side of the surgical breach. (b) Insertion of the suture at the galea level.
(c, d) reduction of the extensive loss of tissue with minimal traction on the wound edges

1,400

1,200 1,200

1,000 1 mm
2 mm
800
3 mm

600 610
580

400 410
360
206 320
200 220
125 158.9
Fig. 4 Correlation between tension and 87.8
extension in the use of the Nordstrom suture 0 57.6
diameters of 1, 2, and 3 mm 100 % 200 % 300 % 400 %
580 M. Greco et al.

a b

c d

Fig. 5 Use of Nordstrom suture in the treatment of large tissue defect in the thoracic region. (a) Prior to tissue excision. (b) Large tissue defect
post excision. (c) Insertion technique of suture material. (d) Postoperative result

Fig. 6 Elastic properties of the suture

The Suture of Nordstrom 581

a b

Fig. 7 Scarring from surgery breast reduction and revision of scars using silicone suture. (a) Diastasis of breast reduction scar, approximately
1 cm. (b) Postoperative result following use of silicone suture to revise scar with clear reduction of the scar, approximately 2 mm

2. Nordström RE, Greco M, Raposio E, Barrera A (2001) The

References
1. Neumann CG (1957) The expansion of an area of skin by progres-
sive distension of a subcutaneous balloon; use of the method for
securing skin for subtotal reconstruction of the ear. Plast Reconstr
Surg 19:124–130
“Nordstrom suture” to enhance scalp reduction. Plast Reconstr Surg
107(2):577–582; discussion 583–585
3. Fan J, Wang J (2004) The “silicone suture” for tissue expansion
without an expander: a new device for repair of soft-tissue defects
after burns. Plast Reconstr Surg 114(2):484–488; discussion
489–490
 Part V
The Nose
 Historical Overview of Rhinoplasty
Carmine Alfano and Salvatore Di Cristo
The Edwin Smith’ Papyrus is the first written document in
which nose surgery is mentioned. Dating back to 1650 B.C.,
according to James Henry Breasted, the papyrus should be a
copy, enriched with 69 explication notes, of a still more
ancient manuscript (dated 2500–3000 BC), which focused
on the analysis of different types of trauma. Of the 48
reported cases on this papyrus (each case was explained from
inspection to the diagnosis and sometimes even to treat-
ment), four of them concerned the nose (XI-A break of the
column of his nose, XII-A break in the chamber of his nose,
XIII-A smash in the nostril, XIV-A wound in his nostril). The
authorship of this precious document has been attributed to
Imhotep, Vizier of Pharaoh Necherjet Dyeser and such a
famous doctor to be deified and worshiped as the Egyptian
God of Medicine [1].
The real development of reconstructive surgery of the
nose, however, began only a few centuries later in India,
between 1500 and 400 B.C. Mutilations, and in particular the
amputation of the nose, were considered regular punish-
ments commonly inflicted on war prisoners, adulterers, trai-
tors, and thieves: although this was happening on a regular
basis, the disfigurements inflicted were so cruel to push
Hindu surgeons to devise techniques to improve the appear-
ance and reduce the social disease of the victims.
Sushruta, the Indian Hippocrates of the sixth century
B.C., in his treatise Sushruta Samhita described, in Sanskrit,
that Indian medicine has used local flaps in reconstruction of
the nose since ancient times.
Many sources attribute also to Sushruta the description of
the use of a strip of rotation from the frontal region for nasal
reconstruction (this solution will be later renamed as the
C. Alfano, MD (*)
Dipartimento di Scienze Chirurgiche, Università di Perugia,
Perugia, Italy
e-mail: profcarminealfano@gmail.com
S. Di Cristo, MD
Private Practice, Naples, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_42
“Indian method”), although in Sushruta Samhita, there is no
other explanation than the one using the genieni flaps.
The frontal flap was in fact already used by the Marattas
from Kumar, near Poona, as well as by some Nepalese families
and Kanghairas of Kangra (the latter were taking care of
deformed and even amputated noses since 1440 B.C.), but those
were operations provided with such secrecy, to remain unknown
for many centuries, even to the Indians themselves [2].
It was with the Arab expansion in the Indian lands that the
Hindu culture was exported first in Arabia and then in Persia
(the Sushruta Samhita was translated into Arabic around the
eighth century A.C.) and from there to Egypt and Italy [3].
The Western world will remain unaware of this Indian
knowledge, at least, until the fifteenth century A.C. The first
to learn the Hindu reconstruction techniques is Augusto
Branca: born in Provence, he settled in Catania, after a long
stay in Persia, and it was here that he learned of these new
techniques. In January 1432, Branca obtained the license to
practice surgery by King Ferdinand I of Sicily, and he recon-
structed noses using local skin flaps, not unlike the Indian
surgeons were doing.
His son, Antonio Branca, began to use a myocutaneous
flap taken from the inner side of the arm to reconstruct nose
and other defects of the face, thus avoiding to leave the
unpleasant and obvious scarring of local flaps (such as geni-
eni flaps and frontal).
This is the first example of a skin flap from a distance in
the history of reconstructive surgery.
The historian, Bartolomeo Fazio in De viris illustribus (1457)
speaks of these techniques that were always wrapped in secrecy:
I think both Branca and his son are particularly worthy of men-
tion because Branca, the old man, was the inventor of an admi-
rable and almost incredible thing. He had conceived how to
rebuild and replace noses that had been mutilated or amputated,
developing his idea in a wonderful art. And his son Antonio
added much to the wonderful discovery of his father and con-
ceived how he could also repair lips and ears as well as nose.
Also, while the father took the meat for the repair from the
patient’s mutilated face, Antonio took it from his arm so that
there were no other disfigurements on his face: on the etched
arm, he applied the stump of the nose and tied so tightly that the
585
586
patient’s head stood still for 15 days, sometimes 20. Then,
slowly he cut the skin flap that was attached to the nose until he
was peeling completely [from the arm] and he modeled it in the
shape of his nose with such perfection that it was hardly possible
to distinguish with the naked eye that the flap had been added, so
that any deformities of the face had been removed. [4]
The brothers Peter and Paul Vianeo of Tropea (known by
some as Boiano) learned and modified this technique (they
carved a skin flap from the forearm rather than a myocutane-
ous flap from the arm) and became so famous in the field of
nasal reconstruction in the sixteenth century, to receive,
without a pause, a multitude of patients from all over Italy.
Like the Branca’s, they also worked in total secrecy [4].
Both Branca and Vianeo were barber-surgeons. During
the twelfth century A.C., the Church discredited surgical
activity (“Ecclesia abhorret a sanguine”), and most of the
doctors of that period began to consider those manual surgi-
cal procedures dishonorable and vulgar, which only became
competence of the barbers. This situation gave life to fami-
lies in which the profession of barber-surgeon was hereditary
(the license was transmissible to offsprings) and where the
operation technique was a real asset to be guarded with jeal-
ousy and passed from father to son.
Leonardo Fioravanti using a cunning ploy discovered the
secrets of the technique of the Vianeos. He, despite being a
doctor, practiced surgical activity. In 1549, he landed on the
coast of Calabria, introducing to Vianeos as instructed by a
friend in Bologna, as rich as unfortunate victim of an ampu-
tation of the nose, to evaluate their real reconstructive capac-
ity. Hiding his profession, he tempted the Calabrian surgeons
with the opportunity for a good profit. The fate was in favor
of Fioravanti: in those days, the son of Senator Albergati was
actually traveling to Tropea, from Bologna, because he had
broken his nose in a duel with a mercenary. Fioravanti due to
this fortuitous coincidence, received hospitality by the broth-
ers Vianeo that in the following days, showed him some of
their cases, and also allowed him to attend one of their opera-
tions. So he wrote in his “Il tesoro della vita humana”:
… Pretending not to see such a thing, they turned back my face,
but my eyes saw very well and so I beheld all the secrets, from
head to foot, and I learned it. And the order is this, the first thing
that they did to one when they wanted to do this operation, was a
purge and then in the left arm between the shoulder and the
elbow, in the middle, they were taking the skin with a forceps and
a big hand went between the forceps and the meat of the muscle
and there passed a small hook or “stricca” of canvas and they
cared as long as the skin became very big. And when it seemed to
them that it was big enough, cut off the nose and everything
seems to cut the skin in a band and stitched nose and bound with
so much artifice and dexterity that you could not move in any way
as long as the said skin was not welded together with the nose and
that was welded, the cut in the other band and flayed the lip of the
mouth and there were sewing the said skin of the arm and take
care as long as it were welded together with the lip. And then, you
put a form made of metal in which the nose grew in proportion
and remained format, but somewhat whiter than the face …
C. Alfano and S. Di Cristo
Fioravanti described in detail what would take the name
of the Italian method of nasal reconstruction [4, 5].
At the end of the sixteenth century, the anatomist and sur-
geon Gasparo Tagliacozzi from Bologna (1545–1599),
understood the value of the method described by Fioravanti
and popularized it in the academic circles, the technique of
pedicle flap, the basis of future development of modern plas-
tic surgery. Tagliacozzi experimented and reached a perfect
technique and described in detail not only the method (also
described in detail the “autonomization of the flap” and the
time of 14 days, which was to elapse between the preparation
and the transfer of the flap), but also the indications, contra-
indications, and possible complications in “De Curtorum
Surgery for Insitione,” giving a strong scientific impression
to a method until then without any academic credentials.
For his insights, Tagliacozzi is universally regarded as
the founder of plastic surgery. Unfortunately, his work was
severely hampered both by some colleagues and by the
Church. Many colleagues appreciated the procedure, but
they challenged the utility: surgery was taking care of the
body, but was not embellishing it. For some surgery teach-
ers Parè and Falloppio, no patient should suffer such an
agony. They judged it would be far better to have a false
wood or metal nose. For the Church, however, every trau-
matic or congenital deformity of the face is the will of God,
which is divine drawing or punishment, and therefore any
surgical procedure, which modified the physical appear-
ance, was a desecration of the divine work. So huge was the
hostility for his statements, that after his death, although
Tagliacozzi was buried in Bologna, in the Church of St.
John the Baptist, he was exhumed and burned in unconse-
crated ground and similar fate befell his writings, banned
and burned.
Despite the work of some distinguished disciples, the
interventions of Tagliacozzi fell into disuse for over three
centuries. During these dark centuries the general feeling of
hostility against medical society supported the ability to
perform an operation using the skin of another person. The
tissue for the transplant was taken from a slave, a servant or
a lender, rented for this purpose thus avoiding any suffering
to oneself. Also supported and disseminated by the ideolo-
gies of sympathetic medicine, there were many stories told
as true, about people who had received transplant body parts
of others and about the special surreal links between donor
and recipient [1, 4].
To discover new interests on nasal reconstructive surgery,
we should be waiting until the late nineteenth century.
In August 1794, on the Madras Gazette and then on the
Gentleman’s Magazine, the following October, was pub-
lished a letter titled “A Singular Operation,” which described
the case of Cowasjee, driver of bulls for the British Army,
who was captured during the war of 1792 against the Sultan
Tippoo Sahib and suffered amputation of the right hand and
Historical Overview of Rhinoplasty
nose. A year later, knocked on the door of the English
Resident at Poona, Sir Charles Malet, a merchant with a
strange scar on his forehead. Sir Malet, intrigued, asked for
an explanation to the occasional visitor who revealed how,
after having suffered the amputation of the nose, a surgeon
from Poona had rebuilt him a new one.
Sir Malet looked for this surgeon, belonging to the
caste of brickmakers, and in the presence of two physi-
cians of the East India Company, Thomas Cruso and
James Findlay, he did operated on Cowasjee and other
unfortunates with similar disfigurements. In the published
letter, there was the description of the use of a front turn-
ing flap for the reconstruction of the nose: the Indian
method was thus officially revealed to the Western world.
The more interesting curiosity, emerging from the descrip-
tion of this innovative intervention, was that the flap, after
being lifted and rotated, was not sutured in the new loca-
tion, but held in place by means of a strips of linen ban-
dage, cemented with a mixture of water and soil. This
document, signed L.B., was long attributed to the English
surgeon Cully Lyon Lucas although the true author was
Barak Longmate [6, 7].
A very English surgeon from Chelsea, Joseph Constantine
Carpue was struck by this letter. Driven by the belief that
English surgery was not any lower, for capacity and means,
of the ones in India, he began to experiment this operation on
corpses. He had the opportunity to perform such intervention
of nasal reconstruction in England then. In September 1814,
after 20 years of waiting, an army officer, whose nose was
deformed by a prolonged exposure to mercury, gave Carpue
the opportunity he has long been chasing. The operation was
performed on October 23, 1814, without anesthesia and with
excellent satisfaction of both surgeon and patient.
Shortly after, the Prince of Wales, later King George IV,
sent another army officer, Captain Latham, who in the battle
of Albuera in Spain, in May 1810, had lost part of his nose.
The success of this second operation also led Carpue to share
his experiences, publishing in 1816 a work called “An
account of two successful operations for restoring the lost
nose from the integuments of the forehead” in which, with
great emphasis he boasted to have completed the operation in
15 min, compared to the hour and half needed by the Indians
[1, 6, 8].
In the same period, Ferdinand von Graefe, professor of
surgery at the Berlin University (as well as general of the
Prussian Army), carried out the first complete reconstruction
of the nose, describing the technique in his text Rhinoplastik,
first plastic surgery treaty, after the one written by Tagliacozzi.
Von Graefe reported three cases of reconstructive rhino-
plasty, performed first by adopting the technique of
Tagliacozzi, then the Indian method/technique, and changing
the Tagliacozzi technique with a transfer, without the
“empowerment” of the brachial flap in the face.
587
His pupil and successor to the chair of surgery in Berlin
was Friedric Johann Dieffenbach, which continued and com-
pleted his master’s studies and first described a technique to
correct a deviated nose cartilage: we are facing the first
example of a corrective cosmetic surgery of the nose. As
described in his Chirurgische Erfahrungen in der
Wiederanheilung zerstörter Teile (1834), the approach was
made through some external skin incisions (in the posts of
the maxilla), which allowed exposing the cartilaginous struc-
tures, after a subcutaneous dissection. After separating the
triangular cartilages from the nasal bone, he contained them
in the new position through the use of patches. With the pub-
lication of Die Operative Chirurgie, in 1845, many surgeons
in Europe were fascinated by the results obtained by
Dieffenbach and adopted his technique.
Although Dieffenbach, already in this work, was dealing
also with the deviations of the septum (cutting the diverted
full-thickness portion and leaving a communication between
the nasal cavities), the first description of a technique of
resection of the deviated septum cartilage, after bilateral dis-
section of the mucosa, belongs to Heylen (Medical Gazette
de Paris, 1847). This technique will be taken up and modified
by many surgeons as Ephraim Ingals (1882), Robert Krieg
(1886), and Gustav Killian (1899). The latter set the founda-
tions of modern septoplasty, performing a more conservative
surgery of the septum, wherein preserving a dorsal pillar and
a caudal one of the quadrangular cartilage reduced the risk of
retraction or secondary deformities of the spine [1, 4].
In 1894, Friedrich Trendelenburg, according to Joseph,
would correct a deviated nose, again through external skin
incisions, acting on the bony structures by lateral and trans-
verse percutaneous osteotomies. Some authors consider this
correction as the first example of aesthetic-corrective rhino-
plasty in the modern sense.
According to another school of thought, it would be rather
down to the interventions of John Orlando Roe, who first
proposed the intranasal route to access the osteocartilaginous
skeleton, the record in this type of methodology. In the first
publication, The Deformity termed “Pub Nose” and Its
Correction by a Simple Operation (1887), Roe illustrated
three cases of the tip bulbous noses and how they had been
reshaped. In the subsequent work of 1891, The Correction of
Angular Deformities of the Nose by Subcutaneous Operation,
the surgeon described three cases of removal of the nasal
hump, using a chisel, through an incision made between the
edge of the bone and the triangular cartilage. From his writ-
ings, Roe shows how much importance he attached to the
functional and psychological aspects of aesthetic and correc-
tive rhinoplasty:
… The nose is the central and most important feature of the face,
and from its shape, size and appearance depends to a large
extent, the beauty of a person’s face…
and still
588
… It is of the utmost importance to keep a perfect nasal breath-
ing, not only for the health and well being of the patient, but also
for a satisfactory correction of the same deformity. The
symmetrical relations of the different parts of the nose together
are of great importance, but we must carefully consider the sym-
metrical relationship of the size and shape of the nose in relation
to the profile of the face, to approach as closely as possible, to
the ideal artistic point of view. It is important to note that a con-
dition of deformity is continuously observed. This is considered
from the patients as a constant source of embarrassment and
psychological suffering, so important to lead to an inferiority
complex. We may be able to improve the conditions of these
patients… [4]
Robert Fulton Weir in his paper “On restoring sunken
noses without scarring the face,” written in 1892, described
how to reshape a nose flattened from a trauma or deformity,
combining the surgical approach of Roe (reshape of the
bones) with the usage of a prosthetic material (for projecting
the back).
Weir describes the use, as a prosthesis, of a bone fragment
of the sternum of a duck to correct the deviated nose of a
patient with syphilis and the subsequent rejection after
7 weeks (this is the first documented use of the graft known
as xenograft), as well as that of a bridge in platinum, success-
fully described.
Also in this publication, Weir identifies the typical patient,
never satisfied with the results, always asking further action
to the surgeon in the pursuit of perfection. Weir also described
a technique for narrowing the nasal openings by removing a
wedge of wing tissue, following incisions placed in the naso-
buccal fold (engraving of Weir).
If Dieffenbach, Roe, and Weir are rightly considered to be
the pioneers of cosmetic rhinoplasty, it is equally correct to
consider Jakob Lewin Joseph (better known as Jacques
Joseph) as the real father of it: He popularized his techniques
with aesthetic purposes, convinced that it was right to help
those who suffered psychologically because of a nose that,
due to its shape or size, was a source of embarrassment or
social unrest.
Although he began working, in 1892, as the orthopedics
assistant of Professor Wolff, Joseph was soon fascinated by
facial plastic surgery. In 1896, he operated a young boy, with
large and prominent ears, who refused to attend school,
because he was the object of ridicule and derision by other
students. Although he was not familiar with any previous
surgery for the treatment of such deformities, Joseph brought
this operation to a successful conclusion (even if he risked
dismissal!).
In 1898, a second patient, embarrassed by the size of his
nose and who did not want to appear in public, turned to
Joseph, who was convinced he could help and began to prac-
tice on a corpse. The operation was successful and then
Joseph published all the details in the Über die operating
Verkleinerung der Nase (1898): the scaling of the nasal pyra-
mid was obtained accessing the transdermal area, by exci-
C. Alfano and S. Di Cristo
sion of a segment “V” upside down on the nasal dorsum,
comprising the skin, the hump osteocartilaginous, and the
nasal mucosa.
When Joseph discussed his results to the Berlin Medical
Society, he introduced a theory perhaps too revolutionary for
the surgeons of that time, who held a purely aesthetic pur-
pose for their operating skills. Joseph, on the contrary, saw a
patient with a look that caused him a social handicap, sick as
much as a patient suffering from a debilitating condition and
therefore held the psychological aspect of plastic surgery as
important as the result of the operation; the research of a
“normal” appearance was not just a matter of vanity, but an
“antidysplasia” feeling. In 1904, Joseph publishes Uber die
intranasal hòckerabtragung, which describes the excision of
osteocartilaginous hump through the intranasal route. We
should wait until 1931, however, for his most brilliant study,
which is undoubtedly the Nasenplastik Und sonstige
Gesichtsplastik nebst einem Anhangůber Mammaplastik,
where in minute details he described and illustrated photo-
graphically his knowledge about the aesthetic reconstruction
of the nose, as well as a review of the main basic techniques
of the plastic surgery. Many surgeons, fascinated by his
works and fame, stayed in Germany to attend his speeches
and learn the secrets of his art. They include Joseph Safian,
who after his studies on complications of rhinoplasty (in par-
ticular on how to reduce the risks and how to treat them)
divulged the results in the Corrective Rhinoplastic Surgery
in 1935 (with whom he also spread the teachings in the New
World), and Gustave Aufricht, who in 1934 published the
work Combined Nasal Plastic and Chin Plastic: Correction
of Microgenia by Osteocartilaginous Transplant from Large
Hump Nose, where he was the first to describe a mentoplasty
augmentation, using the nasal hump just resected.
In 1940, Aufricht introduced the rigid compressive dress-
ing of the operated nose, modeling with a dentist dough in
order to decrease the incidence in the occurrence of frequent
bruising, using only adhesive plaster and gauze [1, 4, 5].
Also in 1934, the German surgeon Eitner, trying to reduce
the risk of infectious complications, suggested detaching the
mucosal lining of the osteocartilaginous skeleton prior to
reshaping the nose. Despite the wonderful insight of Eitner it
was not until FF Rubin and Anderson (Retrograde
Intramucosal Hump Removal in Rhinoplasty 1958) and
especially by Robin (Extramucosal Method in Rhinoplasty
1979) that the technique was made popular.
Again in 1934, the Hungarian Rethy published a work on
reducing the length of the nose by means of a transverse
columellar incision, which tied bilaterally to the undercut
allowing the exposure of the nasal skeleton. To Rethy is
attributed the authorship of the modern open rhinoplasty,
although already, in 1920, Gilles had conducted an open rhi-
noplasty through an incision at the base of the columella,
setting up a flap which he described as “a trunk of an
Historical Overview of Rhinoplasty
Fig. 1 Frank McDowell and James Barrett Brown
elephant.” The open technique will be taken up and modified
by surgeons such as Sercer, Goodman, and Anderson [4].
In 1951, Brown and McDowell published the book Plastic
Surgery of the Nose, which, for nearly a decade, would have
been the most popular text on rhinoplasty: the authors
describe the techniques of subversion of the alar cartilages
(known as delivery) and resection in the shape of a hockey
stick (hockey stick), from the upper excess of the lateral
crura, which is still commonly used (Fig. 1).
The history of the surgery of the nose, that from the second
half of the twentieth century to the present day, is dominated by
the search for more conservative surgical techniques, leading to
a lower occurrence of complications and the respect of proper
nasal physiology (Fomon, Cottle), and the refinement of tech-
niques aimed at reshaping the tip and the treatment of defects
in nasal projection. Remembering all the other surgeons, who
in recent decades have modified the original technique of
Joseph, would result in a sterile and unconstructive list, which
is outside of our purpose. Those who deserve to be mentioned
for their innovations in this field have developed different tech-
niques for correcting the defects of projection through cartilage
grafts such as Sheen (coupling shield) and Peck (umbrella
graft) or technical remodeling of the alar cartilages by Goldman
589
(who dissected the wings and full-thickness skin vestibular and
then sutured the medial crura) and Ponti, all founders of a cul-
tural heritage of inestimable value to any surgeon wishing to
approach the aesthetic and corrective rhinoplasty.
References
1. Symons J (2001) A most hideous object: John Davies (1796–1872)
and plastic surgery. Med Hist 45:395–402
2. Joseph J (1987) Rhinoplasty and facial plastic surgery with a sup-
plement on mammaplasty and other operations in the field of plastic
surgery of the body. Columella Press, Phoenix
3. Santoni-Rugiu P, Sykes PJ (2007) A history of plastic surgery.
Springer, Berlin
4. Campisi A, Polselli R, Saban Y et al (1996) Rinoplastica estetico-
correttiva e mentoplastica additiva. OEMF, Milano
5. Bhattacharya S (2008) Jacques Joseph: Father of modern aesthetic
surgery. Indian J Plast Surg 41:S3–S8
6. Rana RE, Arora BS (2002) History of plastic surgery in India.
J Postgrad Med 48:76–78
7. McDowell F (1978) History of rhinoplasty. Aesthetic Plast Surg
1:321–348
8. Bennett JP (1984) Sir William Fergusson and the Indian Rhinoplasty.
Ann R Coll Surg Engl 66:444–448
 Basic Rhinoplasty
Carmine Alfano, Stefania Tenna, Virginia Ciaravolo,
Antonio Rusciani, and Stefano Chiummariello
1 Background
1.1 General Considerations
In an appearance-based society, the promise of an easy change
of body image has made cosmetic surgery very popular among
surgical specialties, with a tremendous increase in the last
30 years. The shape and size of the nose are important cos-
metic features of any individual. Rhinoplasty allows signifi-
cant changes, sometimes of the whole face, with “invisible”
scars enhancing the idea of “magical” transformation.
In fact rhinoplasty has become the gold-standard opera-
tion in cosmetic surgery, and undoubtedly the most requested
by both men and women of wide-ranging age.
A good result requires a detailed knowledge of the anatomy
of the face, surgical techniques, and respiratory physiology.
Though performed by many surgeons, rhinoplasty
remains a difficult operation and, as Rees stated, “… surgical
technique can be taught to many, but only few become mas-
ters of this art …” [1].
Complexity of execution, multitasking the management
of highly demanding patients (also from a psychological
viewpoint), ability to foresee the final result despite long
recovery time, and being able to predict factors that can
influence convalescence distinguish an expert from a neo-
C. Alfano, MD (*) • S. Chiummariello, MD, PhD
Dipartimento di Scienze Chirurgiche, Università di Perugia,
Perugia, Italy
e-mail: profcarinealfano@gmail.com
S. Tenna, MD, PhD
Dipartimento Centro Integrato di Ricerca (C.I.R.),
Università “Campus Bio-Medico”, Rome, Italy
V. Ciaravolo
Chirurgia Plastica e Ricostruttiva, Università di Roma
“Sapienza”, Rome, Italy
A. Rusciani, MD, PhD
Chirurgia Plastica e Ricostruttiva, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_43
phyte, and make this intervention always a fascinating chal-
lenge for the plastic surgeon [2].
The traditional generic classification divided rhinoplasty
into two broad categories: reductive and augmentation
rhinoplasty.
However manifold the aesthetic deformities of which
patients complain, usually only common alterations of pro-
file such as a marked hump or enlargement and plunging tip
are easily identifiable. By contrast, modifications of the fron-
tonasal and/or nasolabial angle, width of the pyramid, and
shape of the tip are more difficult to highlight, and common
complaints may be totally subjective.
In all patients the goal is to achieve harmony of the nose
with the whole face, given it is easier to shorten and lower
the nose than to narrow it, but functional aspects must also
borne in mind, even for those patients who ask for only an
aesthetic correction.
The final result is always strictly conditioned by the pre-
operative anatomical situation, and sometimes the perfect
technical execution may not be sufficient the nose is not con-
sidered as a component the architecture of the face.
This chapter can be considered a small contribution to the
great debate over rhinoplasty, starting from the basic notions
of so-called primary rhinoplasty.
2 The Concept of Beauty
The artistic vein is the key for a successful aesthetic operation.
(Aufricht)
Alongside the talent a surgeon may possess, the cosmetic
surgeon must also maintain an attitude that considers the
subjective concept of “beauty,” keeping in mind that aes-
thetic commonsense is influenced by race and cultures.
The definition of a “regular” face is still inspired by
Leonardo da Vinci’s proportions of three thirds, established
in the sixteenth century. Beauty results from harmony and
balance between length, width, and height of the nose in
591
592 C. Alfano et al.

Fig. 1 Ideal measurements of nasofacial and nasofrontal angles

relation to adjacent subunits: forehead, medial canthal

regions, nasolabial regions, and upper lip. The line that
delimits the nose should be, in frontal view, a curve that
starts from the head of the eyebrow, follows the side wall,
and reaches the outer edge of the lateral crus; while in a
side view it starts from the upper orbital rim, ending on the
dome.
Leonardo’s proportions coincide with some anthropometric
parameters that identify an aesthetic “standard”: an ideal nose
should occupy about one-third of the face and should be com-
pared with the ear for size and the chin for projection [4, 5].
The root of the nose represents the passage between the
nasal pyramid and the forehead, and coincides with the naso-
frontal angle. This angle normally lies in a parallel plane tan-
gential to the superior orbitopalpebral sulci, and should
range between 150° and 160°. The root of the nose directly
influences the length of the dorsum and the relative tip pro-
jection and, moreover, influences optically the intercanthal
distance (Fig. 1) [6].
The dorsum is the largest aesthetic subunit, additionally Fig. 2 Anatomical subunits of the nose in relation to adjacent
influencing with its length and width the infraorbital and structures
nasolabial regions (Fig. 2). The evaluation of the length,
width, and profile of the dorsum allows identification of
any alteration in the nasal bones, cartilages, and the charac- evaluate the type of deviation in the context of the patient’s
teristics of the side walls constituting maxillary bone facial appearance.
branches. Thus, deviation of the pyramid axis usually Hemifacies often differ, either statically or dynamically,
affects this subunit, and a careful clinical examination for many reasons such as skeletal or soft-tissue asymmetries
together with a cephalometric analysis is recommended to or muscle group actions; in this sense, sometimes a slight
Basic Rhinoplasty
deviation of the pyramid could be more harmonious and
“beautiful” than a “perfect” nose.
Finally the entire face, with its different expressions,
needs to be observed, considering racial features, dental
occlusion, and skin type (thin, thick, or oily), in addition to
skeletal and topographic analysis, paying special attention to
the tip of the nose that represents the only “mobile and ani-
mated” portion of the pyramid.
In all views, the tip should appear as a continuation of
the dorsum with an ideal projection that must be equal to
the length of the nose multiplied by 0.67 [7]. In lateral
view, 50–60 % of the tip should protrude forward from the
vertical plane, passing the most prominent portion of the
upper lip [7].
The passage between the tip and the upper lip is identified
by the nasolabial angle, which, according Micheli-Pellegrini
[5], must be between 90° and 110°.
Recent publications have further improved such criteria,
estimating that this angle should ideally be about 95–105°
for women and 90–95° for men. Morphology and position
of the tip depend on contour and thickness of alar cartilage,
but they are also influenced by skin type and subcutaneous
tissue that may affect tip configuration, especially in some
ethnic groups.
Looking from the nose tip, the width of the base should be
about 70–80 % of the alar width which, in turn, may corre-
spond approximately to the intercanthal distance [6].
Some studies have classified different morphologies for
the alar cartilage, although we tend to consider as natural a
round shape of the tip. The columella must be sufficiently
long to allow adequate projection, and from a lateral view
must be located between 3 and 5 mm below the nostril mar-
gin (Fig. 3) [9].
The tip subunit is therefore the highlight of the pyramid:
prominent or fleshy tips, though of modest entity, may
often significantly alter the harmony of the whole facial
profile [10–12].
Fig. 3 The width of nasal wings should correspond to the intercanthal
distance, and the height of the lobule should correspond to half of the
columella
593
3 Psychological Implications
Proper selection of patients is crucial and necessarily
endures accurate, sometimes multidisciplinary, scrutiny.
Psychological disorders related to the perception of body
image may in fact be multiple, and should also be at least
summarily recognized by the plastic surgeon, to avoid per-
forming a surgical procedure in a psychologically unsuitable
patient [1].
As the nose is a highly distinctive characteristic, the
patient often focuses attention on it as the key element that
determines the harmony of the whole face. Therefore it is not
uncommon, especially during puberty, for individuals to
consider the nose as particularly important, and that even
slight imperfections generate psychological complexes capa-
ble of producing relationship problems.
Though somewhat simplistic, it is therefore appropriate
always pay attention to personality attributes, which are gen-
erally evident from the first consultation (e.g., shyness rather
than arrogance). One can then try to understand the degree of
patient attention toward appearance, even for the smallest
detail, and assess the surgical expectations.
Some patients with psychological problems are easy to
identify, such as those who arrive with photographs of actors
or actresses whom they would like to resemble; others, by
contrast, do not immediately cite their problems.
Making the patient aware of the exact defect complained
of, and how he or she considers it important in social life, is
a crucial step in preoperative assessment [13].
The request for an improvement in physical appearance is
legitimate and therapeutic when it is well articulated and
placed within a sufficient psychological context: the surgeon
must be able to firmly reject any desire for a transformation
that will not benefit from surgical correction.
While not dwelling on the importance of motivations or
high unrealistic expectations of these patients, we emphasize
that collaboration with psychologists regarding dysmorphic
problems is a valid approach, and in some cases allows both
the patient and the surgeon to improve their professional rela-
tionship pre- and postoperatively, identifying the elements of
dissatisfaction and clarifying the goals to be achieved.
Indeed, in these cases the aesthetic operation, even if
technically correct, cannot solve and bring any benefit to
psychological disorders, as it represents only one step in the
evolution of a neurosis [14].
4 Anatomy
The nose is a triangular pyramid with a base formed by the
nasal choanae. It has an osteocartilaginous skeleton that forms
the anchor for the muscular structures, the superficial muscle
aponeurotic system (SMAS) and soft tissue. Externally it is
594
covered with skin, and internally with nasal mucosa. Each of
these structures plays an important role in maintaining form
and functions.
A successful rhinoplasty procedure is based on the respect
of the anatomical and functional relationships among these
structures.
Bones are externally formed by the upper maxillary
branch and the two nasal bones; internally the posterior por-
tion of the septum consists of the perpendicular plate of eth-
moid, and inferiorly the base is formed by the vomer, the
maxilla, and the palatine bones.
The cartilaginous portion comprises two lateral cartilages
(triangular cartilages), two alar cartilages, two sesamoid car-
tilages, and the septal quadrangular cartilage (Fig. 4).
The nasal bones are rectangular in shape and articulate
each other on the median line through the internasal suture,
laterally with maxillary branches through the nasomaxillary
suture, superiorly with the nasal notch of the frontal bone
through the frontonasal suture, and inferiorly continuing with
the triangular cartilages. Nasal bones are two small oblong
bones placed side by side at the middle and upper part of the
face, thinner and flared in the distal part and thicker in the
proximal portion. The maxillary branches articulate medially
with nasal bones and superiorly with frontal bone.
The triangular cartilages are two cartilages that lie on the
middle line of the nose and are inclined obliquely with
respect to the nose’s longitudinal axis; they articulate superi-
Nasal bones
Triangular
cartilage
Triangular
cartilage
Fig. 4 Frontal view of the nasal pyramid anatomy
C. Alfano et al.
orly with the lower nasal bone border, medially with each
other, and laterally with the upright branch of the maxilla in
the upper part and the soft lateral triangle at the bottom.
The inferior edge folds it back and, through the perichon-
drium, continues with the upper edge of the ala medially and
the sesamoid cartilage laterally. The contact point between
the alar and the triangular cartilages is the plica nasi, whose
shape and integrity are important for the internal functioning
of the nasal valve. A section perpendicular to the major axis
of the cartilages forms S-like articulation, owing to alar car-
tilages overlapping the lateral cartilages; these can slide over
one another during inspiration and exhalation.
In the upper portion, lateral cartilages are in continuity with
the septum, while in the lower portion this continuity progres-
sively reduces. This conformation increases their mobility in
the lower portion, as does the action of muscles inserted.
The lateral soft triangle is positioned medially between
the lateral margin of the triangular cartilages, laterally
between the upright branch of the maxilla, and inferiorly
between the superior edges of the alar cartilages.
The septum consists of a bony part and a cartilaginous part.
The posterior bony part is formed by the palatine bone, the sphe-
noid bone crest, and the ethmoid perpendicular crest (Fig. 5).
The septal cartilage articulates through its posterior pro-
cess with the perpendicular plate of ethmoid, superiorly and
inferiorly with the vomer and the maxilla.
The upper portion of the septal cartilage dorsal margin is
closely related to the nasal bones; the median portion is thick
and continues laterally with the triangular cartilages and
moves away from the lower lateral cartilages, delimiting a
so-called weak triangle of Converse, which has a triangular
shape and is composed of aponeurotic structures that serve
the suspensory ligaments of the tip.
The alar cartilages, or inferior lateral cartilages, are equal
and symmetrical. They have a vaulted form whose pillars are
Quadrangular Perpendicular
cartilage ethmoid plate
Nasal crest
of the Vomer
jawbone
Fig. 5 Lateral view of the anatomy of the nasal septum
Basic Rhinoplasty
different in size and shape. The medial pillar gives its name
to the medial crus and the lateral one the lateral crus; between
them lies the vault known as the dome.
Medially the two medial crura move away from each other
in their posterior part,, and anteromedially they are closely
united, forming the columella. The lateral crus moves obliquely
downward and forms the lateral wall of the tip. The shape and
length of the major axis of the lateral crus are highly variable.
The tilt axis of the alar cartilage, its shape, and its height are
important for the constitution of the nasolabial angle: depend-
ing on its orientation, this angle can be open closed.
Its length varies between 18 and 27 mm while its height is
between 10 and 15 mm. Particular interest lies in the study of
its form regarding the tip orientation.
The intermediate crus consists of the lobular segment and
the dome. Its shape and the distance between the two domes
are the basis of the different types of tip termed square,
spherical, fine, or pointed. Between the two domes is a liga-
ment (interdomal ligament or Pitanguy’s ligament) that is
important for tip suspension (Fig. 6).
The Converse soft triangle is located below the intermedi-
ate crus of the alar cartilage, and has been described as an
area of the external vestibule of the nose that must be pre-
served in nasal incisions.
The columella extends from the lobule to the labial phil-
trum. It consists, anteriorly, of the intermediate crus and the
two medial crura, which are intimately connected in the front
part and diverge posteriorly, forming an open angle where
the cartilaginous septum and the nasal spine bone are placed.
Fibrous
connections
Piriform
opening
Suspensory ligament
Fibrous
of the lip
ligaments
Fig. 6 Nose cartilages and their ligaments
595
The medial crura are separated from the septum by a mem-
branous segment called the membranous septum.
The internal nasal valve is an important structure, since it
influences the internal nasal air flow. Anatomically it is formed
by the joint between the superior and the lateral alar cartilages
(plica nasi), the lateral soft triangle structures, the crest of the
piriform aperture, and the medial septum (Figs. 7, 8).
The integrity of these structures, together with the integ-
rity of the nasal muscles and the innervation, is a key factor
for optimal nasal airflow, which is why these structures
should be preserved during a rhinoplasty. Damage to the
nasal fold essentially determines an increase in inspiratory
resistance, as is the case in facial nerve paresis. During a
preoperative study it is also important to evaluate the size of
the inferior turbinates, as normally they are hypertrophic on
the opposite side of the nasal deviation.
The skin covering the osteocartilaginous structures must be
inspected and assessed during the preoperative planning. The
skin is normally thinner and smoother, with less subcutaneous
tissue over the nasal bone and lateral cartilages, with a thicker
and richer glandular component and subcutaneous tissue in
the tip region. Its thickness is important because it allows us to
predict the degree of adjustment of the cutaneous and subcuta-
neous mantle over the modified osteocartilaginous structures.
A thinner skin exhibits more imperfections; a thicker skin
Internal valve
External valves
Fig. 7 Nasal valves
596
Internal
valve
External
valve
Fig. 8 Nasal valves: inferior view
better hides small irregularities but has a longer recovery time
from edema and a lower adjustment because of its minor elas-
ticity (supratip deformity).
Below the subcutaneous mantle, the presence of muscle
aponeurotic structures involved in nasal scaffolding, and
their mobility, is also important.
The nasal muscles can be divided according to their
function:
• Elevators: procerus, levator labii superioris alaeque nasi
• Depressors: alar nasalis, depressor septi nasi
• Compressor: transverse nasalis
• Dilators: dilator naris anterior and posterior
They can be also divided into intrinsic muscles (which
originate in and insert on the nose) and extrinsic muscles.
The procerus muscle continues on the dorsum of the nose
into the pyramidal muscle, and its aponeurosis continues
with the transverse part of the nasal muscle to form the
SMAS of the nose.
The nasal muscle consists of two parts, transverse and
alar. The transverse part arises from the maxilla, above
and lateral to the incisive fossa; its fibers proceed upward
and medialward, expanding into a thin aponeurosis, which
is continuous on the bridge of the nose with that of the mus-
cle of the opposite side, and with the aponeurosis of the pro-
cerus. The alar part is attached by one end to the greater alar
cartilage and by the other to the integument at the point of
the nose. This is the muscle responsible for “flaring” of the
nostrils.
The levator labii superioris alaeque nasi belongs to the
extrinsic muscles; it dilates the nostril and elevates the upper
lip, enabling one to snarl, and in some individuals it may
C. Alfano et al.
become part of the nasal musculature of the medial orbicu-
laris and the zygomatic minor muscles.
The depressor septi nasi may be more or less repre-
sented, and has been described in three variations: one in
which the fibers end on the orbiculari oris, another in which
the fibers end on the periosteum, and a third, rudimentary
type consisting predominantly of a rudimentary fibroapo-
neurotic beam.
By observing nose mimicry we can evaluate how much
these muscles are represented. In certain cases, the section of
the distal part of the septum depressor and their subsequent
suture allows better visualization of the upper lip area, to
maintain constant the rotation and projection of the nose
even during movement. All of the aforementioned muscles
participate actively in nostril movement during breathing
[1, 4, 12, 15, 16].
4.1 Vascularization
4.1.1 Arterial System
Arteries of the nose belong to the ophthalmic and the facial
arteries. The ophthalmic artery is the first branch of the inter-
nal carotid artery distal to the cavernous sinus and terminates
in two branches, the supratrochlear (or frontal) artery and the
dorsal nasal artery. The latter exits the orbit medially, run-
ning laterally to the nasal bones until the nose tip. It supplies
the proximal portion of the nose and contributes to the sup-
ply of the subdermal plexus of the tip.
The facial artery continues into the angular artery, which,
during its course, contributes branches to the lip and nose. The
lateral nasal artery is a branch of the facial artery, arising later-
ally to the nasal ala, which runs downward laterally to the alar
cartilages until the nostrils where, with some small branches,
it contributes to the blood supply of this area. The inferior
branch instead distributes to the upper lip and produces the
columellar artery that runs toward the tip, anastomosing with
the lateral nasal artery. The two vascular systems form an arch
at the top of the ala, running below the musculoaponeurotic
system. Both the ophthalmic and the facial arteries, with their
branches, supply the subdermal system (Fig. 9).
4.1.2 Venous System
The venous system also runs above the SMAS along the side
wall, the dorsum, and the tip of the nose, draining into the
facial and angular veins. The lateral nasal vein is one of the
major veins of the nose and runs along the nasal vault
perichondrium.
4.1.3 Lymphatic System
The lymphatic system lies superficial to the SMAS. The lym-
phatic drainage takes place laterally to the nose, above the
lateral crus, throughout the piriformis opening, and through
Basic Rhinoplasty
Angular
nasal artery
Arches
Angular artery
Facial artery
Branch for
columella
Superior
labial
artery
Fig. 9 Vascularization of the nasal pyrimad
the parotid gland lymph nodes. The columella region has no
lymphatic drainage.
The tip is supplied by two arterial vascular systems, the lat-
eral nasal artery being the most important. This explains why
the open technique, if properly executed, can scarcely create tip
necrosis, as it affects only the columellar artery. Particular care
should be taken if the patient has undergone interventions that
may have damaged the lateral nasal artery. The same artery will
also be damaged if the surgeon does not preserve 2 mm of the
alar cartilage while performing a surgical incision.
The ideal dissection plane is the alveolar plane; the SMAS
must be left intact to avoid pain and skin necrosis.
Defatting of the tip must be performed with caution, as it
is vascularized by the subdermal plexus. Correct plane
detachment reduces edema formation.
We should also be careful not to damage the nasal vault
venous system, since it is the more efficient venous drainage
system, and damage to it may result in a greater persistence
of postoperative edema.
4.2 Respiratory Mucosa
The nasal cavities are covered by respiratory mucosa of rosy
and shiny aspect, consisting of a multilayered cylindrical
epithelium with cilia and a lamina propria. In more exposed
areas of the mucosa, such as on the nasal conchae, a stratified
squamous epithelium may be present.
The epithelium is formed by hair cells and goblet cells.
The highly specialized hair cells are responsible for the con-
version of the swirling airflow into a laminar one, and also
597
allow air humidification. The goblet cells are intercalated
among the others and are responsible for mucous secretion.
The lamina propria is looser on the outer surface, with
lymphocyte clusters, and is dense and more adherent to the
periosteum or perichondrium on the inner part. Tubule aci-
nar glands with serum mucosa secretion are present in the
underlying connective tissue. The role of nasal secretion is
to trap foreign particles and protect against infectious
agents such as fungi, bacteria, and viruses via the presence
of lysozyme, a lytic bacterial wall enzyme, and immuno-
globulin A (IgA).
Vessels arising perpendicularly from the deep branches of
the periosteum guarantee the vascularization of the respira-
tory mucosa. They form a first deep network in the lamina
propria and a second network at the subepithelial level.
Arteriovenous shunts exist between these two networks,
equipped with a rich myoepithelial system responsible for
the nasal congestion caused by various stimuli. In certain
areas the capillaries are arranged to form erectile structures.
The orthosympathetic system determines vasoconstric-
tion of the capillary system, whereas the parasympathetic
system promotes vasodilation and has a secretory function.
There is a rich venous cavernosus plexus at the level of
the middle and lower concha.
In a wide zone of the septum called the locus Valsalvae,
mucosa continues with skin and the lamina propria takes
the appearance of well-vascularized papillae, reaching the
epithelium. For this reason, epistaxis is quite common in
this area.
4.3 Olfactory Mucosa
The olfactory mucosa is a specialized epithelium that covers
the lamina cribrosa of the ethmoid, the upper part of the sep-
tum, and the mucosa of superior concha. It consists of a cov-
ering epithelium (olfactory cells, supporting cells, and basal
cells) and a lamina propria.
The olfactory cells are specialized nervous cells whose
outer portion takes the form of a button (olfactory vesi-
cle) from which originates small olfactory fibers. The
deep part of the olfactory cells continues with the olfac-
tory nerve.
Among the olfactory cells are the supporting cells which,
in addition to their supporting role, produce and secrete a
glycoprotein material that surrounds the olfactory cells.
The basal cells are instead in close contact with the neu-
ritis and wrap around the axons as Schwann cells. In this
part of the mucosa, the lamina propria is characterized by
a lymphocyte-rich dense connective tissue. The olfactory
glands (glands of Bowmann) are located inside the lamina,
and their secretion seems to act as a solvent for odorous sub-
stances (osmophore).
598
5 Physiology
The nose is the main airflow entry of the body. Each day
about 10,000–20,000 L of air passes through the respiratory
system. The quality and quantity of airflow depend on the
integrity of the nasal anatomical structures and the environ-
mental and endogenous factors that influence it.
External temperature, tobacco smoke, inflammatory pro-
cesses, infections, and stress may all influence nasal airflow.
In the past the nose held an important olfactory function,
which over time has been reduced, localizing mainly at the
level of the mucosa of the lamina cribrosa of the ethmoid.
The high specialization of the nasal mucosa explains the
important respiratory, olfactory, and immunological roles
played by the nose.
While passing through the nasal cavities, air is cleaned
and filtered from corpuscular particles captured by the
mucous serum secreted by the respiratory mucosa. Initially
the air has a swirling flow that is converted in the lamina by
fine vibrating cilia movements, and is heated and humidi-
fied by these vibrating cilia depending on the external
temperature.
The lysozyme, together with IgA, plays a primary non-
specific immune function of defense in the nasal secretions.
The specialized olfactory epithelium is located in the lam-
ina cribrosa of the ethmoid, in the upper portion of the sep-
tum, and in the superior concha. The olfactory function is
strictly dependent on the airflow, and voice resonance varies
in cases of important nasal obstruction.
The nasal valve is the narrowest portion and, thus, con-
fers greater resistance to airflow. During inspiration there
are negative pressures, with positive pressure during exha-
lation. Surgical alterations of the nasal valve can seriously
affect inflow resistance. Weakness or deformity of the alar
cartilage can reduce the size of the nasal valve [3, 5, 17].
6 Preoperative Evaluation
6.1 Medical History and Physical
Examination
The medical history of a patient undergoing rhinoplasty is
essential. Family history of bleeding and a personal history of
bruising or bleeding may imply a blood dyscrasia. Even
women who do not present with true hemophilia can be carri-
ers, and may show a tendency toward serious and dangerous
postoperative bleeding resulting from coagulation disorders.
Whenever there is the slightest suspicion of a bleeding ten-
dency, as in these cases, a careful study of the clotting time
and all coagulation parameters becomes mandatory.
It is useful to bear in mind that many individuals are com-
monly chronic users of aspirin and anti-inflammatory drugs
C. Alfano et al.
(NSAIDs). A personal history of consumption of these drugs
is important because of their significant anticoagulant effect.
All compounds containing aspirin should be suspended for
at least 10 days before surgery.
A history of allergic diseases, such as vasomotor rhinitis,
alerts the surgeon because these patients may suffer worsen-
ing of the underlying disease during the postoperative period.
Therefore the surgeon must warn the patient that the inter-
vention could increase such symptoms for a long period, and
this fact must be included in the informed consent. Otherwise,
the surgery should be delayed in the case of a respiratory
tract infection.
A history of traumas of various type and gravity alerts the
surgeon because of the possibility of finding diverted and/or
misplaced anatomical structures. Instrumental tests are use-
ful to highlight these conditions, and are recommended
before surgery.
Furthermore, personal information about any drug abuse
should be comprehensive. The increasingly and extensive
nasal use in today’s society of drugs, such as cocaine, can
cause avascular necrosis and perforation of the septum, in
addition to atrophy and scarring of the mucous membrane.
Last but not least, patients who have taken psychotropic
drugs must be evaluated not only for possible adverse effects
during the operation or the anesthesia, but also for the possibil-
ity of being affected by psychiatric disorders. The patient’s psy-
chological history should always be reported and psychiatric
patients, especially those who are dysmorphophobic, must be
considered as unsuitable for a rhinoplasty operation [10, 18, 19].
Physical examination of the nose starts peremptorily from
the study of balance and harmony of the face. This rule is
often not well considered, although it is crucial for maintain-
ing harmony of the overall framework of the face.
The shape, the position, the size and volume of the fore-
head, the orbital region, the cheeks, the lips, and the chin
should be carefully evaluated, as all may influence surgical
correction. Any eventual face asymmetry should be pointed
out to the patient [6].
The nose examination can start with its appearance and
anatomy, followed by its functions.
Physical examination of the nose profile allows evalua-
tion of the nasion point, the nasofrontal angle, and the naso-
facial angle, and whether the dorsum is kyphotic or “saddle.”
One then continues by evaluating the supralobular incisors,
the tip along with the projection–nose length relationship,
the columellar–lobular complex with columellar shape and
protrusion, and the columellar–lobular angle. Finally, the
nasolabial angle is measured.
The front and oblique (three-quarters) views allow study
of the nose root, highlighting its symmetry, width, projec-
tion, supraorbital and dorsal curvature; the nasion; the dor-
sum (length and symmetry); the tip, with all its features such
as projection and width of the domes; the supralobular inci-
Basic Rhinoplasty
sors; the columellar–lobular junction; the angle of diver-
gence between the lateral crura of the alar cartilages; and the
alar complex of the columella (columella projection and
width of the nasal wings).
To an expert eye shadows and reflections are important,
highlighting the different aesthetic units of the nose. Finally,
observation of the nose with the head extended allows evalu-
ation of the nostrils, columella, lobule, and wings, with vari-
ous features such as their insertions, dimensions, and
orientations. It should be kept in mind that the female nose
has a better definition than the male nose [19].
At this point the evaluation of the skin, muscle, and carti-
laginous and bone structures begins.
Skin examination plays a major role: a thick, seborrheic skin
retracts soon after the intervention, in an unpredictable way. By
contrast, a skin that is too thin tends to highlight any bone and
cartilage imperfections. The skin’s appearance is strictly related
to the patient’s age and to any previous rhinoplasties regarding
the presence of atrophies, adhesions, and/or retractions.
The surgeon proceeds with palpation of the bony pyra-
mid, evaluating its length in comparison with the cartilagi-
nous portion of the nasal pyramid and the width of the lateral
osteocartilaginous junction.
Examination of the shape and strength of the septal, trian-
gular, and especially alar cartilages, is important for assess-
ing the possibility of correction of the nasal base. The best
surgical outcomes are obtained in the presence of rigid carti-
lage and thin and elastic skin.
External nasal masses may represent a variety of diseases,
such as nasal glioma, dermoid cysts, and encephalocele.
Nose palpation is useful in patients with facial trauma to
distinguish a localized fracture from a LeFort fracture. The
surgeon should observe the incisors and their eventual move-
ments [20, 21].
Anterior rhinoscopy, a fundamental aspect of the preopera-
tive visit, is performed through a nasal speculum and a coaxial
light source. The rhinoscope is introduced with the tip directed
slightly laterally in the nasal vestibule. The nasal speculum
spreads the nostril, and aligns it and the vestibule with the
limen nasi, the narrow opening to the inner nasal cavity. This
maneuver can cause discomfort to the patient when the nasal
speculum is in contact with the sensitive respiratory mucosa of
the inner surface of the nose. Initially the patient’s head is held
in a vertical position to allow the examiner’s eyes to be parallel
with the nasal plane. The patient’s head is then tilted back
slightly to allow the upper part of the nose to be examined. The
medial cavity and the turbinates are thus highlighted.
The maximum backward tilt permits exposure of the eth-
moid region and the olfactory fissures. With anterior rhinos-
copy one can examine:
• Nasal secretions, their color, quantity, and characteristics
• Presence and amount of mucus and/or pus,
599
• Firmness and color of the turbinates,
• Quality of nasal mucosa: whether it is dry, smooth, moist,
polypoid, or irregular
• Septum position and deformity
• Abnormal pigmentation or color of the mucosa
• Presence of tumors and pathological tissue
• Presence of foreign bodies
However, anterior rhinoscopy often does not allow obser-
vation of the vault and the rear wall of the nasal cavity,
including the superior turbinate, the cribriform plate, and the
sphenoid sinus. The structures present in the middle meatus
are not well displayed with the speculum [11–14, 16–21].
6.2 Instrumental Examinations
Plain radiographs of the skull in anteroposterior, lateral, and
submental-vertex projection are basic elements for the study of
the facial skeleton and the osteocartilaginous vault. One may
also require a particular low-energy X-ray or “soft ray” image
of the skull to better study the cartilaginous components. In
some cases, especially when there is a suspicion for previous
facial trauma with nasal pyramid involvement, it may be useful
to perform a computed tomography (CT) and/or magnetic res-
onance imaging study of the cephalic extremity.
Rhinomanometry is an instrumental test that serves to
measure the nasal airflow resistance and obstruction, involv-
ing evaluation of the nasal and airflow pressure. The airflow
resistance derives from two measurements: differential pres-
sure transducers measure nasal airflow and differential trans-
nasal pressure.
The nasal airflow is measured with a pneumotachograph,
for which a small tube is inserted into the nostril or a mask is
applied on the face. The transnasal pressure is measured by
comparing the nasopharyngeal pressure with that in the
external nostril, which usually corresponds to the atmo-
spheric pressure.
Normally the measurements are made during spontane-
ous breathing. The airflow volume passing through the nose
during active nasal breathing is registered together with the
differential pressure of the nose. The data are shown on an
x–y diagram or as two separate sine waves on an oscillo-
scope. The x–y diagram provides information divided into
four quadrants. By convention, upper right and lower left
quadrants are used for nasal airflow, and upper left and lower
right quadrants are used for left nasal airflow. The flow–pres-
sure line is curved because at high levels of resistance, the
nose airflow becomes more turbulent.
After registering the nasal resistance, it is compared with
normal values. A nasal resistance above the 95th percentile
is considered abnormal. Rhinomanometry is a useful method
to document a possible nasal obstruction and to check
600
improvements after surgery, especially nasal septum devia-
tion surgery.
Often, endonasal endoscopic examination can provide
numerous advantages over anterior and posterior rhinoscopy.
This procedure evaluates the morphology of a possible sep-
tum deviation, the turbinate shape and volume, and the nasal
valve, especially the conjunction between the triangular and
the alar cartilages. In addition, one can better study the nasal
vault, the posterior nasal cavity, and the cribriform plate.
To carry out endoscopy successfully it is necessary that
the nasal cavity is decongested and well numbed, which
allows a longer observation time compared with the afore-
mentioned rhinoscopic techniques [1, 10, 18].
6.3 Photographs and “Morphing”
The photographic documentation of the patient is of funda-
mental importance, both to provide information about the
preoperative condition of the nose for each individual case
and as protection from any medicolegal disputes with unsat-
isfied patients.
Preoperative photographs are useful for providing a view
of the “original” nose during the operation, explaining to the
patient the corrections to be made, highlighting face asym-
metry, and providing scientific material for conferences and
scientific publications upon patient authorization for the use
of personal data.
In recent years surgeons have moved from traditional
photography to digital imaging, although some still prefer to
use the classic “photographic film.”
The ideal environment is in which shoot pictures is in an
ad hoc setting, with a fixed lighting system to obtain images
with the same brightness and setting features, such as back-
grounds, lights, and camera.
In this setting, the patient sits on a swivel stool against a
neutral background, the camera is fixed on a tripod, and two
electronic light sources, placed laterally, light the patient’s
face symmetrically at the time of shooting.
The background is one of the most important elements,
even in the absence of a specialized room: it can be black,
green, or blue, but must have a uniform color and be the
same for both preoperative and postoperative photographs.
Normally there are four poses. The first is frontal, whereby
the face of the patient is placed in such a way that the
Frankfurt plane, from the upper part of the tragus to touching
the infraorbital rim, is horizontal. The central part should be
centered on the nose.
In the second projection, which highlights the nares and
alar-columella-upper lip complex, the patient’s head extends
backward, emphasizing the base of the nose.
The last two projections are the left and right profiles.
The patient is rotated around 90° and the nose is always in the
C. Alfano et al.
center of the photographic field. In addition to these projec-
tions one may also take shots in three-quarters pose, since
these are useful for studying the harmony of the female face:
the dorsum line should continue with the eyebrow line. Some
authors also recommend taking photographs (profiles) while
the patient is smiling, to study the movements made by the
nose tip during facial muscle contractions.
The postoperative photographs are taken 1, 3, 6, and
12 months after surgery, using projections and technicalities
identical to those of the preoperative poses.
“Morphing” is the graphic processing of the preoperative
digital images, using special software to allow the surgeon to
modify, on a computer screen, the patient’s preoperative
image during the preoperative visit. With this method the
surgeon can show the patient, in broad terms, the intended
rhinoplasty result. This gives the patient a global idea of the
new aspect of the face, and allows the surgeon to set guide-
lines regarding the patient’s “desires,” with the changes
shown on the amended images. Use of such software pro-
duces an overall preview of the rhinoplasty result.
It should be emphasized, however, that “morphing” may
be a double-edged sword because although on the one hand it
allows the patient to view the future modifications of the rhi-
noplasty intervention on his or her face and lets the surgeon
more fully understand the needs and desires of the patient, on
the other hand it can be extremely dangerous in the event of a
future medicolegal controversy.
The patient, in fact, may claim that he or she did not obtain
a precise preoperative preview. In fact, no one can guarantee
that the postoperative result will equate with the preoperative
preview; the dynamic reality of a face is differs greatly from
a picture, and morphing obtains is a mere photographic elabo-
ration that betrays the photogenicity of the patient.
We must also bear in mind that scarring plays a funda-
mental role in any surgery, especially in rhinoplasty, and is in
no way contemplated during a computer morphing; it is an
unpredictable process regarding its influence on the various
tissues of the nose and the final aesthetic outcome. An “early”
or “delayed” scarring, in addition to the various forms of
pathological scarring, may dramatically change the final
result in a negative way.
Finally, the patient may use the morphing as a probe of
the aesthetic result the surgeon has “promised” him or her in
a hypothetical forensic controversy, whereby it may be very
difficult for the surgeon to prove that the use of digital pro-
cessing was merely for demonstration purposes and not to
show the explicit final result [19].
6.4 Informed Consent
Even the best plastic surgeon, an expert in rhinoplasty,
can encounter legal problems following a presumed or
Basic Rhinoplasty
effectively bad result. Informed consent represents a
weapon of defense for the surgeon in the increasing num-
ber of medicolegal disputes. Informed consent is a docu-
ment whose primary purpose is to certify that the patient
is well aware of the choice being made by the surgeon,
particularly with regard to possible risks and benefits of
the desired procedure [19].
Informed consent has a legitimate legal value; its purpose
is to protect both the surgeon and the patient from errors or
misunderstandings. The surgeon has the duty, during preop-
erative visits, to provide the patient with essential informa-
tion to allow an evaluation of the treatment proposals
amounting to a clear and fair choice: informed consent does
nothing more than list the information received and certify
that this has actually been understood, rather than simply
provided. Informed consent is also generally used for per-
missions requests, especially in respect of any emergency
procedures, or for specific uses of the clinical and photo-
graphic documentation.
The information contained must precisely clarify the
available techniques for the patient’s problems, mentioning
both the advantages and disadvantages of each method; the
different therapeutic alternatives, surgical and nonsurgical;
and the description of the surgical risks, focusing on possible
complications.
Moreover, the frequency with which complications
occur should be illustrated in addition to their eventual
treatment. It is useful to indicate the type of anesthesia to
be applied and the possible complications and risks associ-
ated with it, even providing an anesthesiologic informed
consent. Information should be given about the postopera-
tive therapies and controls, and the risks associated with the
refusal of postoperative follow-up. Finally, the patient’s
authorization may be required for shooting photographs
and their storage [1].
The information must be provided to the patient in a clear
and understandable language, preferably with the aid of
illustrative material. If photos of other patients are shown it
must be clarified that the results differ from patient to patient,
and, above all, that the surgeon has been given permission to
display other patients’ photos.
When using graphics computer processing, one must
indicate that their purpose is to facilitate the discussion and
understanding of the results of a specific technique, and that
the elaborations are not images of the patient’s specified final
result.
Informed consent should be given to patients at least 1 or
2 weeks before surgery, thus giving the patient enough time
to clarify all doubts and put any questions to the surgeon;
during a second meeting the patient will bring back the
informed consent form, adding the dates when the patient
was given all the information and when the consent form was
signed and returned to the surgeon.
601
A further informed consent concerns authorization for
personal data processing in accordance with the privacy pro-
tection regulations.
The pattern of general information and the informed con-
sent protocol on rhinoplasty, drawn up by the Italian Society
of Plastic, Reconstructive and Aesthetics surgery (SICPRE),
is described here [22].
6.4.1 Information about Rhinoplasty
General Information
Rhinoplasty is a surgical procedure whose purpose is to
improve the aesthetic appearance of the nose and face. The
improvement is achieved by reduction and remodeling of the
cartilaginous and bony skeleton. The degree of improvement
varies from individual to individual, and is influenced by the
quality of the skin and the size of the underlying skeleton.
Physical activity should be limited for 2 weeks to avoid swell-
ing or discomfort. Driving may be resumed after 1 week.
Intervention
Aesthetic rhinoplasty requires an operating room, and can be
performed under general anesthesia or in neuroleptanalgesia
that consists in the intravenous administration of drugs that
induce a state of mental relaxation and calm. In addition,
local infiltration with anesthetic and epinephrine is usually
performed when the patient is asleep, to eliminate even the
slightest discomfort resulting from the injection.
The operation is painless. The choice of the type of anes-
thesia can be discussed with the anesthetist. However, maxi-
mum safety measures are always guaranteed. The incisions
are performed inside the nasal vestibule. The skin is mobi-
lized from the underlying skeleton. The hump, if present, is
removed and the nasal bones are fractured at the base to be
better approached in case of dorsum reconstruction.
Septal and lateral cartilages are then isolated and reduced
as much as necessary for a tip remodeling. The dressing is
made with tampons in both nostrils and with the application
of a plaster on the back of the nose to immobilize bones.
Sometimes it may be necessary to combine with the cos-
metic rhinoplasty the correction of a deviated nasal septum.
This accessory procedure is performed through the same
incisions of the aesthetic operation.
What to Expect after Surgery
A certain degree of edema (swelling) in the postoperative
time is normal and may be abundant, especially if the abra-
sion involved the eyes and lips contour; this edema reaches
its maximum on the second and third postoperative day, to
then slowly disappear within a week. During the first night
the patient may feel a slight stinging or throbbing pain, easily
controllable with mild analgesic drugs. The involved areas,
once repaired, will be of an intense pink color that will last
602
for a period ranging from 8 weeks to a few months. In the
first 2 months small whitish granules may appear on the skin,
which generally disappear spontaneously.
Preoperative Preparation
Patients are advised not to take aspirin or aspirin-containing
drugs for 2 weeks prior to surgery and 2 weeks after. Aspirin
can cause bleeding, therefore increasing the risk of compli-
cations. We also recommend avoiding any type of face
make-up to on the day of the intervention. Patients should
stop smoking at least 2 weeks before surgery. In the imme-
diate postoperative period and in the early days we recom-
mend a liquid diet with soft and lukewarm foods. Patients
using oral contraceptives should stop taking them 1 month
before surgery.
7 Anesthesia
For a good rhinoplasty procedure, excellent anesthesia is
necessary. The role of the anesthesia is, in addition to annul-
ling the pain sensitivity, to obtain a cleavage plane through
hydrodissection and to reduce bleeding.
The reduced bleeding facilitates the identification of the
anatomical plane, reduces operative time, and minimizes
postoperative morbidity.
The rhinoplastic intervention, depending on the patient’s
emotional state and the modifications to be made, can be
performed:
• In sedation combined with local anesthesia
• Under general anesthesia with endotracheal intubation
Local anesthesia combined with sedation may be useful
in cases of small adjustments, especially those of the tip; oth-
erwise, is not recommended in the case of major repairs or
providing bone fractures, and with anxious patients. This
psychological aspect is important and must be evaluated,
because the mechanical stress generated by the hammer may
induce movements of the patient’s head during surgery and
may also cause emotional shocks.
General anesthesia, with orotracheal intubation, guaran-
tees control of respiratory function and allows the operator to
work in tranquility.
The local infiltration of anesthetic is of primary impor-
tance for rhinoplasty. Normally xylocaine 1 % with epi-
nephrine concentrations of 1:1,000 are used. The epinephrine
concentration is essential to obtain a vasoconstrictor effect.
Infiltrations with bupivacaine at the end of surgery to pro-
long the analgesic effect, have also been reported in the
literature.
Before performing the infiltration with a local anesthetic,
some authors insert inside the nasal choanae tampons soaked
C. Alfano et al.
with oxymetazoline or cocaine 4 %, a vasoconstrictor that
acts on alpha-2 adrenergic receptors.
During infiltration it is important to follow some basic
rules:
• Anesthetic should be placed according to the dissection
plans of structures to be modified
• Once infiltrated, it is necessary to wait a minimum of
10 min to obtain the vasoconstriction hemostatic
effect
• Infiltration facilitates the plane dissection, ensuring ade-
quate hemostasis and that it does not distort the anatomi-
cal structures
The sequence of zones to be infiltrated can vary according
to surgeon preference. One can start from the outside and
then infiltrate the mucous planes, or vice versa. We recom-
mend using 30-gauge needles for the tip and 27-gauge nee-
dles for the septum and dorsum.
Starting from the septum, the infiltration is performed
with a 27-gauge needle, following a subperichondrial and
subperiosteal extent. The beak of the needle tip should be
positioned with the opening facing the cartilage, and the
infiltration should be performed while raising the mucosa
until obtaining its partial bleaching. The infiltration of the
septal mucosa should only concern the septal area of
interest.
After the septum, infiltration continues in the caudal
margin of the septum, so as to infiltrate indirectly the mem-
branous septum. Next the surgeon proceeds with infiltra-
tion of the piriformis fan opening using a finer needle. The
nasal side wall is infiltrated through an intercartilaginous
access, on a supraperiosteal and supraperichondrial level,
inserting the needle for the entire length of the side wall
and infiltrating while slowly extracting the needle. The
amount of surface to be infiltrated depends on how one
wants to free the dorsum and the nasal side walls to per-
form osteotomies. The alar cartilages are infiltrated from
their lower edge with multiple injections; to better reveal
this edge it is useful to proceed with nostril subversion with
the thumb and forefinger of the left hand. Finally, the colu-
mella is infiltrated from the top, from the dome level,
inserting the needle perpendicularly, from top to bottom,
between the two medial crura. The nasal tip is infiltrated
into the subcutaneous side, positioning the needle in the
interdomal region and directing it toward the lateral crura at
the level of the anterior septal angle. Some surgeons also
infiltrate the glabella and the point-break.
In cases where rhinoplasty is performed under sedation, it
is important to perform an infraorbital nerve block.
The infiltration of this region is carried out without
adrenaline, injecting about 2 mL of 1 % or 2 % lidocaine
[1, 3, 15].
Basic Rhinoplasty
8 Surgical Technique
8.1 Incisions
Different rhinoplasty techniques may be performed
through two access routes: the intranasal and the so-
called open routes (termed “open rhinoplasty” in the lit-
erature). A correct exposition of the osteocartilaginous
structures it fundamental for a perfect rhinoplasty [1, 3].
A “four-season” access no longer exists; one must choose
the best depending on the clinical case. The surgeon who
is about to perform a rhinoplasty should be able to master
many techniques and so be able to choose, without any
prompting, the most appropriate one for achieving the
best possible result while at the same time drastically
decreasing the risk of complications. In our opinion, the
endonasal access is the most appropriate, while we
reserve the open technique for particular clinical condi-
tions. Open rhinoplasty is described in another chapter in
this volume.
Joseph first used the intranasal route when he described
the rhinoplasty technique [23], the principle of which is to
isolate the osteocartilaginous structure from the soft tissues
in order to reshape it. In this manner, the morphology of the
nose is transformed with redistribution of the covering tis-
sues that saddle the new structure by exploiting the healing
capability.
Mucosa can be sectioned, depending on the technique,
without detachment (transmucosal technique), or by separat-
ing it extramucosally from the osteocartilaginous skeleton
(extramucosal technique) [18, 20, 21].
The intranasal access has the advantage of avoiding the
transcolumellar scar that sometimes may remain evident
and depressed, which may create marked psychological
problems for the patient and also appears as a “stigma” of
rhinoplasty [1, 11, 16]. The endonasal technique avoids
edema of the soft parts, which can persist over time; the
risk of skin necrosis is also nonexistent. Any complications
arising from inaccurate or unfortunate use of the open
access can be much more serious and difficult to hide than
those arising from the endonasal access. The advantages of
open access are the excellent exposure of the anatomical
structures, especially of the lower third of the nose, and the
possibility to make their correction easier, especially in
situations most difficult to resolve (eg, post-traumatic seri-
ous nasal deformities or malformation, secondary and ter-
tiary rhinoplasty).
There is no precise rule about the time course of a rhino-
plasty; each surgeon prefers and can choose a different suc-
cession of surgical times. We prefer to treat primarily the
middle third and the top, while other surgeons give prece-
dence to the lower third of the nose (tip), treating the nasal
dorsum later.
603
The basic steps of a rhinoplasty are:
• Vestibular and septum membranous incisions
• Separation of the soft tissue from the bony and cartilagi-
nous structures
• Subperichondrial separation of the septum mucosa
• Separation of the triangular cartilages from the quadran-
gular cartilages of the septum
• Treatment of the cartilaginous and bony dorsum
• Basal fracture of maxillary branches
• Treatment of triangular cartilages
• Treatment of alar cartilage
• Suture of the incision and dressings
The typical intersecting columellar incision is performed
by no. 15 blade using a double hook.
The narinal vestibule is everted; the lateral incision can be
intercartilaginous or transcartilaginous.
The intercartilaginous incision is made along the upper
edge of the lateral crus, along the border with the caudal
margin of the triangular cartilage; triangular cartilage sepa-
rates the alar cartilage from the triangular cartilage [3, 4,
10, 18] (Fig. 10). The incision is prolonged laterally,
depending on the planned cartilage resection and on the
possible dissection of the rear extension of the alar carti-
lage. The same incision is repeated on the opposite side,
extending the two incisions toward the two domes and con-
tinuing into the membranous septum: here the incision
becomes transfixed (Fig. 11). With curved blunt scissors
the separation of the membranous septum and the region
above the tip is completed. The incision is then extended
toward the nasal spine on the basis of required exposure
and the desired effect. A major release of the membranous
Fig. 10 Incisions: marginal, transcartilagenous, and intercartilagenous
604 C. Alfano et al.

septum and a major subperiosteal dissection of nasal spine
muscle insertions determine the tip regression and the
lowering of the upper lip; this action is taken in the event of
an excessive nasal projection with an open nasolabial angle.
The transcartilaginous incision [3, 4, 10, 18] affects the
intermediate and lateral crura of the alar cartilage, allowing a
resection of the excess cartilage. We recommend performing
this type of approach in cases of thick skin, narrow nostrils,
and hard alar cartilage (Fig. 12).
The transcartilaginous incision allows resection of a part
of the alar cartilage, which is dissected with direct access up
to the triangular cartilage and the sesamoid cartilages.
Next, elevation of the nasal skin mantle from the deep
support structures is performed with a straight-blade scalpel
for the pyramid sides and with a curved-blade scalpel for the
dorsum. Alternatively, one may use blunt and curved scissors
(Ragnell’s scissors) for the same dissection (Fig. 13). The
detachment involves a plane external to the perichondrium of
the triangular cartilage and external to the periosteum of the
frontal apophysis [10].
Width and depth of the dissection depends on the skin
thickness.

8.2 Transmucosal and Extramucosal

Dissection

After making the transverse incision of the membranous

septum, helped by sharp scissors, one searches for the
right dissection plane located in the subperichondrial
space.
Having made the mucosal breach, a cartilage dissector is
Fig. 11 Transfixion incision of membranous septum
introduced throughout (Fig. 14) which must separate the

Fig. 12 The transcartilagenous

incision involves the lateral and
the intermediate crus of the alar
cartilages and the mucosa
adherent to them (a). Mucosal
dissection is performed in a
bottom-to-top direction. The
cartilaginous resection is
performed after the incision (b)
Basic Rhinoplasty
Fig. 13 The musculocutaneous plane is separated from the osteocarti-
laginous structure of the nose by Ragnell scissors
Fig. 14 Dissection of the fibromucosa from the border of the triangu-
lar cartilage
fibromucosa along the ventral margin of the quadrangular
cartilage, for a width of 6 mm and for the whole margin
length, up to the plowshare and the perpendicular plate of the
ethmoid. A second dissection involves the caudal margin:
this will facilitate quadrangular resection when, toward the
end of the intervention, the desired rotation angle of the tip is
evaluated [12, 16, 23, 24].
Using an Aufricht elevator the detached tissues are ele-
vated, revealing the dihedral angle formed by the union of
the quadrangular cartilage with the triangular ones. At this
point, pushing downward toward the nasal cavities, the
605
Fig. 15 Separation of the triangular cartilages of the nose
detached fibromucosa will form a space in which to insert
the scalp for the separation of the triangular cartilage from
the quadrangular cartilage (Fig. 15).
This surgical step makes possible the extramucosal tech-
nique. Described by Eitnerin in 1932 in Austria and revised
later by Fomon in 1939, Anderson in 1958, and gradually by
other authors [9, 12, 18, 24–26], this technique separates the
mucosa from the deep part of the triangular cartilage, the
septum, and the nasal bones, passing in the subperiosteal and
subperichondrial plane:
In this way the osteocartilaginous structure is completely
skeletonized before rhinoplasty is carried out. Furthermore, the
extramucosal approach respects the mucosa, passing through a
bloodless plane and allowing complete isolation (cavity closed)
of any cartilage or bone grafts from the nose cavity.
Many authors [16, 18, 21, 24–26] believe that by using
this technique, work on the osteocartilaginous structures
is made easier and more accurate. Other advantages are
the lower intra- and postoperative bleeding, and decreased
edema. Figure 16 highlights the resection lines for the osteo-
cartilaginous dorsum with the extramucosal technique,
while Fig. 17 shows the condition of the dorsum and mucosa
after basal osteotomy and the shrinkage of the dorsal roof
(described later).
For the transmucosal technique the mucosa and the
osteocartilaginous structure must first be sectioned, without
606
Fig. 16 Line of resection of the osteocartilaginous dorsum using the
extramucosal technique
Fig. 17 Condition after basal fractures and dorsum resection with
preservation and lowering of the mucosa
detachment [1, 18, 19, 21]. The drawback of this technique
is the establishment of a communication with nasal fossae,
which limits use of the graft. Another disadvantage is the
risk of retraction of the intranasal mucosa. The details of
this technique are described in Fig. 18, which shows the line
of resection and the situation at the end of the intervention,
with excursion of the mucous folds between the segments of
the frontal process.
C. Alfano et al.
Fig. 18 Resection of the dorsum using the transmucosal technique
After isolating and exposing the septum cartilage, the tri-
angular cartilage, and the higher bony structures, resection of
the quadrangular cartilage and triangular cartilages is per-
formed. The Aufricht elevator is repositioned and, with the
help of angled quadrangular scissors (about 130°), a quad-
rangular strip of length and height corresponding to the pre-
viously elaborate graphic project is resected (Fig. 19).
Meanwhile the triangular cartilages are remodeled and low-
ered to the same height as the square.
8.3 Hump Reduction
Treatment of the nasal dorsum, in general, provides a surgi-
cal reduction of the profile [1, 3, 16, 18, 23]. Resection of the
osteocartilaginous structure must be carefully considered,
and the resections must be parsimonious so as to avoid
unsightly surgical outcomes.
The nasal dorsum can be concave, convex, straight, or
deflected. The concave dorsum may be congenital,
post-traumatic, or iatrogenic. The convex dorsum is usually
congenital, but can have a post-traumatic or iatrogenic origin,
although with different characteristics. The straight dorsum
presents as regularly projected, or hypo- or hyperprojected.
The deviated dorsum presents, in primary position, a broken
or curved line with a right or left concavity.
Surgical correction of the concave dorsum is carried out
essentially through the use of grafts and is treated as
described in the section on grafting. The hypoprojected
straight nose undergoes adjunctive therapy with grafts, while
Basic Rhinoplasty 607

Fig. 19 Resection of the ventral

quadrangular border

the hyperprojected dorsum is treated with profile reduction

surgery. The deflected dorsum, of course, forms part of the
discussion on nasal septum correction.
Here we describe the surgical technique used for reduc-
tion of dorsal kyphosis, also called dorsal hump or
rhinokyphosis.
With the aid of the Aufricht retractor one can observe a
typical profile line, nicknamed “bayonet” because of the pro-
trusion of the bony hump, resulting from of previous reduc-
tion of the quadrangular cartilage (Fig. 20).
At this point, a Joseph periosteum retractor is used to
remove the periosteum from the nasal bones just at the point
where the osteotomy will be performed by a chisel. Some
surgeons prefer major periosteal detachments, but we usu-
ally pull out only the portion of periosteum necessary for a
successful osteotomy.
Hump reduction may be carried out by chisel, rasp, or
saw, but we prefer the former, using the rasp only for revising
and modeling the resection performed.
The chisel we use must have the cutting line slightly
greater than the nasal dorsum width so as not to abrade the
overlying skin; it must also have bilateral guidance.
The chisel or osteotome is placed at the inferior edge of
the frontal processes, at a level determined both by preopera-
tive photographic projections and the intended ideal result,
and by the height of the already performed cartilage (quad-
rangular) resection (Fig. 21).
At this point, the assistant surgeon gives a few taps at the
end of the instrument with a hammer. The operator holds the Fig. 20 “Bayonet” hump resulting from previous reduction of quad-
rangular cartilage
608
Fig. 21 Hump osteotomy with scalpel
chisel firmly and checks the correct progression of the instru-
ment. In general, the first tap is of “commitment,” allowing
the operator to engage the chisel at the nasal bone level,
while the second is of “cutting,” allowing the chisel to prog-
ress to the nasal bones and cut them. When it arrives about
1–2 mm from the junction of the nasal bones with the frontal
bone, a lever movement is performed that will allow, by
means of pliers, removal of the bony portion of the kyphosis.
Next, the rasp levels out any irregularities and, if necessary,
lowers the dorsum.
Other methods are also described in the literature for
hump reduction, such as use of the rasp, hand or electric saw,
and the Rowland osteotome. We recommend the use of the
rasp only for small kyphosis, given that the rasp produces a
considerable amount of bone and periosteal chips that have
to be completely removed from the subcutaneous space;
these chips are potentially harmful to the final rhinoplasty
outcome.
We do not usually employ either the hand or electric saw
because of the major laceration of the periosteum and the
large number of frustules produced, which can create prob-
lems over time.
The median fracture is always included in the treatment of
the nasal dorsum [1, 3, 16, 18, 23] and is done by the chisel,
weakening the upper part of the nose roof. Median fracture
C. Alfano et al.
Fig. 22 Resection of the remaining bony wedge, after hump osteot-
omy, at the cranial junction between septum and nasal bones by a chisel
can be performed before or after basal fractures of the frontal
process of the maxilla, in cases where the pyramid bony
walls are still held by a bony bridge, in the frontal-nasal
region, which obstructs the approach of the frontal process
toward the midline.
After treatment of the dorsal kyphosis, a chisel of about
5–6 mm wide is positioned on the surfaces of the perpen-
dicular plate of ethmoid, in the frontal-nasal region, and is
tapped with small hammer strokes in the sagittal plane for
2–3 mm, before withdrawing it once again (Fig. 22). In this
manner the maxillary branches are released from their upper
medial connections. As a result of this procedure, the maxil-
lary branches will approach more easily on the midline with
digital pressure and a lateromedial tilting movement after the
baseline fracture has been performed.
8.4 Treatment of the Nasofrontal Angle
After treating the osteocartilaginous hump, the surgeon deals
with the nasofrontal angle [10], which strictly depends on
obliquity of the front and dorsum. The nose-root depression
is located at the upper eyelid when the patient’s gaze is in the
primary position. The entity of this depression depends on
the glabellar prominence and the skin thickness. Surgical
correction of an angle that is too small is easier than one that
is too open. In the first case it is sufficient to lower the
Basic Rhinoplasty
kyphotic or upright dorsum and then to adjust its balance in
comparison with the frontal inclination. The use of a carti-
lage or bone graft to fill this angle is uncommon.
In the presence of an excessively open angle, a bone
resection of the frontal inlet using a very sharp chisel or a
small rasp is necessary; this maneuver will produce a nose-
root recess. This procedure must be avoided in the case of
exophthalmos morphology. The covering skin retracts
shortly after this osteotomy, especially if its thickness is
relevant.
8.5 Treatment of the Nasolabial Angle
The nasolabial angle, in theory, should be between 90° and
100°. It depends on the position of the lip and the columella,
which is why a careful physical examination is essential for
planning a rhinoplasty [10].
The etiology of a closed nasolabial angle can arise from
different situations.
In the case of a too oblique downward and forward upper
lip, the patient presents a “short face” secondary to the pres-
ence of a retromaxilla. The smile poorly uncovers the teeth,
if at all.
The angle correction requires an osteotomy to advance
and lower the upper jaw, leading to an open nasolabial angle.
In the case of smile deficit when the exposure of the incisors
at rest is normal, it is sufficient to perform a resection of the
lower edge of the septum and of the nasal spine (Fig. 23).
The horizontal position of the columella, and specifically
of the lower edge of the cartilaginous septum that reduces the
columella, is another condition that may determine a closed
nasolabial angle. In this case, where the smile and the incisor
exposition are normal at rest, the nasolabial angle correction
only requires resection of the lower edge of the septum with-
out changing the insertion point of the septal cartilage on the
nasal spine; the inferior resection of an anteriorly based tri-
angle opens the nasolabial angle without changing the lip
position.
Fig. 23 The resection of a cartilaginous string from the inferior part of
the septum and of a piece of the anterior nasal spine elevates the tip and
increases the upper lip height
609
If the position and the shape of the medial crus give a
closing appearance of the nasolabial angle, the correction to
be made should produce a rotation of the upper tip. It almost
always requires not only resection of the joint between the
triangular cartilage and the alar cartilage, but also of a rear
extension of the lateral crus. The angle opening of the apex
of the columella is achieved with a medial crus chondrot-
omy; a cartilage graft can also be used to reinforce the crus.
It should be noted that the use of a graft can lower the rear
part of the medial crura; the positioning of a graft under the
cartilaginous septum and nasal spine lowers the columella
and opens the nasolabial angle (Fig. 24).
An open nasolabial angle has a different etiology and thus
requires a different treatment. The presence of a lip retrusion
with a too vertical upper lip requires an advancement of the
dental arch, generally performed by an advancement osteot-
omy of the maxilla.
However, in the presence of an upper rotation of the colu-
mella with a protruding nose from the septum or nasal spine,
the correction requires resection of the septum and possibly
of the nasal spine.
8.6 Osteotomies
Bilateral basal osteotomy is performed with a rounded osteo-
tome, usually through the intranasal route or, alternatively,
the vestibular or transcutaneous route. After making an
Fig. 24 The positioning of a graft under the cartilaginous septum and
the nasal spine lowers the columella and opens the nasolabial angle
610
incision at the lower part of the piriform opening, the perios-
teum is taken away, partially or completely, from the upright
branch of the maxillary with a Joseph retractor along the
osteotomy projection [1, 2, 6, 7, 16] (Figs. 25, 26).
Fig. 25 Line of the basal osteotomy, which can be done continuously
or with subsequent drillings
Fig. 26 Lateral osteotomies are generally performed through an inci-
sion on the lower part of the piriform aperture
C. Alfano et al.
This incision starts in the lower part of the piriform opening
in the upright branch of the maxilla, heading toward the inter-
nal canthus and passing ahead of it. The incision then goes up
into the compact bone of the nose root, although it can be real-
ized below this level, especially in the case of a narrow root
(Fig. 27), for which a curved osteotome may be required.
The bilateral basal osteotomy, upon incision on the vesti-
bule side wall of and subperiosteal dissection, can be recti-
linear, or slightly arcuate or oblique, and in some cases may
be supplemented by a transversal osteotomy (“low to low”
osteotomy); a bone triangle often remains after this opera-
tion, which must be removed with a rongeur, as it could hin-
der the nose reduction along the median line [3, 10, 12, 18].
In the straight basal osteotomy (“low to high” osteotomy)
the bone-section line directs vertically from the bottom
upward and ends at the internal angle of the eye, medial to
the anterior lacrimal crest.
The transverse osteotomy is performed with a swallow’s
tail osteotome, completing the basal osteotomy and allowing
the nasal bones to come together on the midline.
A useful technical trick during a basal osteotomy is to
guide the chisel obliquely to obtain a bone section that
increases the contact between the bony parts previously
mobilized. Alternatively, a transdermal osteotomy with a
2-mm chisel may be performed.
Is important to bear in mind that the upper limit for a
transverse osteotomy is several millimeters under the naso-
frontal suture, and that the lateral extension depends on the
type of basal osteotomy previously performed.
The bone fragment remaining after the osteotomy can be
moved laterally, a maneuver known as “out-fracture.” At the
level of the frontal notch, two bony triangles are then resected
by a gouge forceps. This frontal notch resection should not
be excessive, so as not to interrupt the harmonious curve of
Sheen of the nose root. The bone fragments are then kept to
the median line through manual compression [3, 10, 12, 18].
Alternatively, the bone fragments may be approached
immediately with digital pressure on the median line, a
maneuver known as “in-fracture” (Fig. 28).
Resection of triangles from the frontal bone with the for-
ceps must be performed before the fracture.
The choice of the type of fracture to be performed varies
according to surgeon preference.
8.7 Treatment of Triangular Cartilage
This is the last surgical stage in the methodological sequence
before treating the nasal tip [18]. One must remember that
the height of the cartilage has already been adjusted during
resection of quadrangular cartilage. The reciprocal relation-
ship between the ventral margin of the quadrangular carti-
lage and the edge of the triangular cartilage must be checked.
Basic Rhinoplasty
Fig. 27 The osteotomy incision
depends on the width of the nose
root, and can be low (1) or high
(2). The osteotome should be thin
to avoid the nasal bones breaking
The three edges must lie on the same plane. At this stage, in
craniocaudal direction, the length of the triangular cartilages
must be symmetrized after reducing the cranial expansion of
the lateral crus; and one must ensure that the cranial margin of
the resected lateral crus is in contact with the lower edge of the
triangular cartilage [11]. The contact depends on the ampli-
tude of the resection of the lateral crus, and on the shape and
size of the caudal edge of the quadrangular cartilage previ-
ously resected to obtain the cranial rotation of the tip.
The caudal apex of the triangular cartilage is then dis-
sected from the intranasal mucosal surface; the lateral sur-
face of the cartilage is already free from connections, for
which the cartilage apex is in a prime location and eminently
visible. The triangular cartilage is resected with extreme pre-
cision. The amplitude of the triangle is evaluated to connect,
as already explained, the caudal margin of the triangular car-
tilage with the cranial margin of the alar cartilage [12, 24].
In this way the triangular cartilage is shortened (Fig. 29).
8.8 Surgery of the Tip
Giving a natural shape to the tip of the nose is one of the
major goals in rhinoplasty; thus, the approach to this region
must be extremely systematic and gradual. Imperfections of
the tip are frequent (>80 % of cases) and usually affect more
than 90 % of the domes and lateral crura [16].
Numerous techniques have been described to achieve the
three main objectives of projection, alar cartilage shape, and
balance with other volumes. In recent years the use of
remodeling techniques, less traumatic and more conservative,
611
have offered clear benefits in terms of reproducible and natu-
ral results, especially for less skilled surgeons.
Tip surgery can be performed at the beginning of a rhino-
plasty, but always requires a re-evaluation after correction of
the dorsum and osteotomy [6, 8, 18].
In fact, changes are related to modification of the osteo-
cartilaginous dorsum such as its shortening and shrinkage
through lateral osteotomy, and are related to nostril
reduction.
It should be kept in mind that, especially for the tip, cor-
rections have to be absolutely precise since even a few mil-
limeters can change the nose morphology and produce
unnatural and unsatisfactory results.
Surgical techniques for the alar cartilage can be classified
according to the type of resection, incisions, sutures, or
grafts. In any case, methods that preserve the cartilaginous
arch can be distinguished from those that provide its inter-
ruption and require its restoration [1].
It is wrong to think of developing a universal technique
for any type of defect; however, it is true that virtually every
surgeon uses a preferred technique.
That being said, resection of the lateral and intermediate
crus with the Joseph “hockey-stick” technique is certainly
one of the most used, since it allows a natural-appearing nose
reduction.
The techniques providing the separation of the domes and
their suturing or the lowering by decapitation of the domes
themselves, or the weakening and the formation of new
domes, are common techniques but are rarely used because
of a cosmetic result that can sometimes be considered unnat-
ural [1, 6, 16, 25].
612
Fig. 28 Fracture of the bony part at the
level of the frontal incisors. (a) Out-fracture:
the fragments are shifted upward with an
osteotome. (b) In-fracture: the bidigital
pressure allows approximation of the two
fragments
Fig. 29 Resection of the lower apex of the triangular cartilages
C. Alfano et al.
8.9 Access Routes
It is important to know anatomy in detail and the possible
variants of the structures, and to be familiar with at least two
different access routes and structure exposure techniques. In
fact, one should prepare and visualize the alar cartilage prop-
erly before any reduction techniques, modeling, or simple
incision, remembering the basic rhinoplasty principle “it is
not important what you remove but what is left…”.
The access routes are divided into external and intranasal.
The three intranasal routes are the intercartilaginous, the
intracartilaginous, and the marginal [26].
The intercartilaginous incision is made in the recess
formed at the junction between the lower edge of the triangu-
lar cartilage and the upper alar cartilage edge. This incision,
performed alone, is considered an access route to the nasal
pyramid rather than to the tip, but when combined with the
marginal or paramarginal incision, it allows an excellent dis-
play and eversion of the lateral crura and domes (Fig. 10).
Basic Rhinoplasty 613

By contrast, the intracartilaginous incision is made about

at half of the lateral alar crus, taking care with the area of
domes where the cartilage shrinks rapidly. The incision
begins at the apex of the vestibule, approximately 3 mm from
the caudal margin of the lateral crus, then extends laterally
and cranially, usually affecting full-thickness skin and carti-
lage. Particular care must be taken to maintain at least 5 mm
of caudal crural edge to ensure the contour of the nostril
(Fig. 12).
This access allows exposure of the crura in a retrograde
manner, and is widely used during classic interventions with
planned partial resection of crura (Fig. 30).
The marginal incision coincides with the distal edge of the
lateral crura; normally it is performed in combination with
other accesses to obtain a better visualization and exposure of
the cartilaginous structures. It is important to bear in mind
that the lower edge of the lateral crus does not run parallel to
the edge of the nostril; rather, in its lateral portion it tends to
rise upward, so it is most important to carefully determine this
portion before performing the incision (Fig. 31).
The exposure of the alar cartilages can be achieved retro- Fig. 31 Marginal incision
gradely (through intra- or extracartilaginous incision) or by
combining the marginal incision with the intercartilaginous
one, sectioning the alar cartilages from the above skin and of the cartilaginous arch, and to Safian in 1934 and then
dislocating outward with a bipedicle flap (Fig. 32). Brown and McDowell in 1951, who detailed the technique of
The history of nasal surgery dates back to Joseph in 1898, combined intercartilaginous and marginal incisions for
who first described the intracartilaginous incision with direct access to external dislocation of the cartilage, with the aim of
excision of a strip of the alar cartilage, to McIndoe in 1951, remodeling with and without interruption of the cartilagi-
who described the retrograde technique without interruption nous arch [1].

Fig. 30 Example of eversion of the lateral crus (a) and medial crus (b) during a retrograde dissection via an intercartilaginous incision
614
The external route instead provides a scar on the colu-
mella and can be done:
• In the sagittal direction, medium columellar (very rare)
• In the transverse direction, horizontally (most frequently
used)
Emilio Rethi described the transcolumellar transverse inci-
sion for the first time in 1934. Most surgeons recommend it in
secondary or tertiary rhinoseptoplasty, or for correcting the nasal
scars secondary to lip and palate cleft. However, recently it has
been re-assessed as a useful access route even in more complex
primary cases, in so-called narrow noses, and in the presence of
small nares or when positioning grafts is necessary.
The external route, completed with the marginal incision,
allows exposure and visualization of structures of the middle
and lower part of the nose [2, 27].
This incision can be straight but the V type is preferred,
better if upside-down V or step-like, to prevent retractions.
Fig. 32 Exposition of the crura via a bipedicle flap according to the
“delivery” technique
Fig. 33 Representation of the different transcolumellar incisions
C. Alfano et al.
Usually it must be performed at the border between the lower
and medium third of the columella, in any case not beyond
half of the columella. The flap dissection must be accurate,
hugging the cartilage to preserve a certain thickness. In addi-
tion, the wound suture should be scrupulous and margins
should be approximated exactly to avoid future depressions
or small nicks, especially in lateral view [4] (Fig. 33).
8.10 Resections
8.10.1 Joseph’s Resection
This technique represents the first published method for tip
correction and is therefore considered a basic technique,
even if the changes proposed later, especially by Brown and
McDowell, have obviated its use.
Skin and cartilage are incised transversally at the junction
between the lateral and medial crus. Another small incision of
about 1–2 mm, perpendicular to the first and parallel to the
nostril edge, is then carried out, involving the dome region. A
triangular spicule, with the apex toward the caudal dome,
comprising both the cartilage and the pseudomucosa nasal lin-
ing, is cut. The craniocaudal portion of the lateral crus is then
excised, but only in its cartilaginous portion (Fig. 34) [1, 15].
This method is particularly aggressive for the dome and
can easily reduce wide tips, but if incorrectly performed can
easily lead to disconnection of the dome, collapse of the
nasal ala, or “pinching” of the tip.
8.11 “Hockey-Stick” Resection
(Brown and McDowell, 1951)
This is among the most widely used techniques and is an evo-
lution of the Joseph method. It can be performed easily with
any access, and is often preferred retrogradely. After exposing
the dome and the lateral crus, the incision to be performed
should have the shape of a hockey stick, starting medially at
Basic Rhinoplasty 615

Fig. 35 “Hockey-stick” resection

Fig. 34 Scheme of Joseph’s resection, a technique which inspired

other later techniques

the level of the outer projection of the dome and extending

laterally for about 1–1.5 cm parallel to the nostril edge.
This incision crosses the lateral crus, preserving the most cau-
dal edge for at least 3 mm. The rest of the cephalic portion the
crus (up to approximately two-thirds) is resected (Fig. 35) [1].
The pseudomucosa and the skin are always preventively dis-
sected so that the excision exclusively involves the cartilage. Fig. 36 The “hockey-stick” resection permits the tip to shrink and
Medially to the outer edge of the dome, the incision must move upward
join the starting point, being careful not to resect the dome.
Since this is a particularly thin area, any excessive removal
can determine secondary tip deformities (Figs. 36 and 37).

8.12 “Butterfly Wings” Technique

In 1953, Goldmann described an operation particularly

indicated for medial crura modifications, valid not only to
decrease but also increase the tip projection, based, via a
delivery approach, on a full-thickness separation (cartilage
and skin of the vestibule) of the lateral crura from the
domes. In addition to the interruption of the cartilaginous
arc by the dome separation, the technique sutures
the medial crura to each other, resulting in a verticalization
of domes and an increased projection of the tip (Fig. 38) Fig. 37 “Hockey stick” resection lets you pinch and rotate the tip
[8, 12]. upward
616 C. Alfano et al.

Fig. 38 Goldmann technique

Subsequently, in 1969 Ponti, maintaining the skin of the

nasal vestibule intact and then proceeding only with the car-
tilage interruption, further perfected this method. The Ponti Fig. 39 Reduction of medial crura and domes following “hockey
version prevents scar contractures and limits excessive motil- stick” resection
ity of the columella; nevertheless, this technique is easily
recognizable from its outcomes.

8.13 Lipsett’s Technique

This technique is more advanced than previous ones and is use-

ful for the correction of overprojection of the nose. The access
can be “open” or via a double marginal and intercartilaginous
incision, leading to exposure through dislocation of the alar car-
tilage bipedicled flap (delivery), followed by cartilaginous inter-
ruption of the medial crura and their shortening. The dome is
morselized and lowered to create a new dome (Fig. 39) [6, 24].
The surplus lateral crus is then resected. Subsequently,
the medial crura and the remaining upper portions are is
sutured. This technique requires sufficient surgical experi-
ence but also provides good correction, even of columella
deformity (Fig. 40).

Fig. 40 Lipsett technique

8.14 Fragmentation
Sometimes it is possible to perform a weakening, rather than
resection, of the cartilages which, even if not in excess, are
poorly positioned or with inadequate convexity/concavity. In
these cases, or sometimes in combination with other resec-
tion techniques, it is possible to make a full-thickness inci-
sion on the cartilage to weaken and bend it, obtaining the
desired curvature.
The incisions must be carried out with particular care so
as not to damage the skin or the buccal pseudomucosa and
the perichondrium. Normally these incisions are made using
an external approach or a delivery; they can be linear “mesh-
like,” “cross-like,” or performed with cutters (scarification)
(Fig. 41a, b) [1].
8.15 Grafts
Even for the tip of the nose, grafts may be considered a sep-
arate issue. Although Rees, in his most recent treatises,
complains of their sometimes indiscriminate use, it should
be underlined that although there are difficulties in obtaining
Basic Rhinoplasty
Fig. 41 (a, b) Examples of crus and dome fragmentation
appropriate modifications of projections, the use of grafts is
sometimes essential [1, 15, 24].
Grafts are autologous materials taken from the same
patient and then replanted in a different location.
The most common donor site is the nose itself: both the
septum cartilage and the cartilaginous part in excess from the
crura are used as grafts. In the case of pronounced defects or
especially for secondary and tertiary defects, or for lipopoly-
saccharide outcomes, it is possible to use the ear, particularly
the concha, which can be easily reached through a retroau-
ricular access.
The grafts can be positioned in different points and used
for different purposes, both functional, such as the “spacer”
graft of Sheen, and aesthetic, such as for corrections of the
nasolabial angle, tip projection, or tip morphology [6].
The most important graft for “structural” modification of
the tip is the so-called strut graft, which consists of an inter-
crural columellar graft and is used to maintain or increase tip
projection.
There are two variants: “floating”, whereby the graft is
placed between the medial crura about 2–3 mm from the
anteroinferior nasal spine, and “fixed”, whereby the graft is
fixed to the medial crura by PDS mattress sutures [4, 27–29].
Usually, for the struts the preferred donor site is the septal
cartilage, with the withdrawal of a rod of at least 3 × 25 mm.
In the case of the fixed variant, one should carefully choose
the sutures from four possibilities:
• Intercrural suture
• Interdomal suture
• Intradomal suture
• Septum-crural suture
617
The execution of at least three of these sutures, in addition
to ensuring the perfect positioning of the graft, guarantees a
better and durable projection.
Among the grafts described for the tip reconstruction we
should mention the “floating” graft, so called because it is
kept in place without any suture but by elastic forces natu-
rally exercised by the integument, with an immediate cos-
metic improvement of the profile, which, depending on the
contoured shape, provides various aspects including the “lath
or stick” shape of Goldman, the “shield” described by Sheen
(Fig. 42), the “swallow” of Aiach and Levignac, or the
“comma” described by Nicolle [8].
In the 1980s this concept was revisited by Peck, who
defined it as an “onlay graft” (Fig. 42) based on an additional
idea, which could also be combined with a strut graft, thus
introducing the so-called umbrella graft [21].
Onlay grafts, especially if taken from the concha or the
crura, with the correct curvature and dimensions (approxi-
mately 6 × 8 mm), can be positioned through a small unilateral
marginal incision and are not sutured. Usually they are posi-
tioned under the lobule or on top of the domes. In fact they can
be placed more precisely by an external route or a delivery
approach, and can be sutured to ensure their position. The
dimensions must not be less than 6 × 8 mm; if using septal or
auricular cartilage they can be made more malleable and mold-
able by a cracker, especially if “floating” grafts are used [1].
In preoperative assessment of the patient, if one wants to
or is obliged to use grafts, the quality and type of skin must
always be evaluated, since if the skin is very thin the posi-
tioned graft can be seen through the skin.
The choice of the access route is also worth several con-
siderations: the external route offers the considerable
618
Fig. 42 Shield (Sheen) graft
and on-lay (Peck) grafts
advantage of visualization of the middle and lower nose
structure and allows for more precise positioning; on the
other hand, it requires complete plane detachment and
causes more postoperative edema.
In this sense, endonasal access routes sometimes
allow, especially for “onlay” grafts of the tip, housing
within a pocket formed from the surrounding structures,
which ensures graft positioning without requiring
stitches.
Finally, grafts can also be used for nasolabial angle cor-
rection, positioning on the lower anterior nasal spine, or
withdrawing composite grafts, especially from the auricle,
for alar margin reconstruction [16, 20].
8.16 Corrections of the Alar Cartilages
The alar base may require, though less frequently, a separate
correction through an external resection. The alteration may
C. Alfano et al.
regard only the length/width of the wing basal portion or
additionally the nostril size.
In cases of wing hypertrophy not associated with
enlarged nostrils, one can perform triangular excision of
the alar skin, localized at the internal sulcus between the
wing and the upper lip. This incision, usually hidden in the
conjunction fold between the two different aesthetic units,
should not reach the nasal vestibule but only involve the
skin portion.
More commonly, however, this kind of alar hypertrophy
is associated with wide nostrils, so it is necessary to remove
a wedge cartilage-skin wing from the alar base, extending at
least 2 mm into the nasal vestibule; in addition to reducing
the base width, this also reduces the nostril width, restoring
a more harmonious appearance.
To modify the size and orientation of the wedge, various
methods have been proposed, including those of Weir and
Herlyn and (the most widely used) Converse and Sheen as
modified by Rees (Fig. 43) [1, 6, 21].
Basic Rhinoplasty
Fig. 43 (a) Scheme of converse
alar resection. (b) Weir
technique. (c) Rees technique
9 Postoperative Management
Proper postoperative management is important in ensuring a
successful rhinoplasty, and involves both the patient and the
surgeon. It is important that before the operation the patient
is informed in detail about the rules to be observed after sur-
gery, the possible complications, and their management [1].
9.1 General Rules to be Followed by
the Patient
• Apply ice bags during the first 24–48 h without
compression
• Sleep with the head raised up until the disappearance of
swelling and bruising
• Avoid foods that can strain the muscles of the mouth in
the first 2 weeks
• Avoid sports and activities in which direct hits on the nose
are possible for about 3 months
• Avoid making major efforts for at least 3–4 weeks and
gradually start to take up a more challenging activity
• Avoid blowing, sneezing, and inhaling forcibly
• Do not wet the nasal split
• Contact the surgeon in case of bleeding, increased tem-
perature >38 °C, anxiety, and pain
• Do not wear glasses for 1 month
• Do not expose the face to the sun during the hottest hours
and protect the skin with sunscreen for about 6 months
• Wash the nose with saline solution and apply gomenol oil
to soften crusts
619
9.2 Possible Consequence
of the Intervention
Swelling usually reaches a maximum around 72 h after the
operation and then disappears within 1 year; bruising will
disappear over time, as will pain, anxiety, and loss of blood
on the gauze positioned below the nasal tampons [1].
9.2.1 Nasal Tampons
These are placed in the cavities just after the operation, and
consist of a spongy material. Some surgeons prefer to wrap
them with antibiotic ointment, others with hemostatic
ointments. Their purpose is to avoid formation of mucoperi-
chondrium or mucoperiosteum hematomas and formation of
scarring synechiae, and to protect the mucosa and stabilize
the changes made. They are held in place for about 7 days
and in some cases, when the intervention on the septum is
more massive, for 10 days. When modifying the septum and
the turbinates, the Doyle septal split should be used [1].
10 Medication
Medication is crucial in stabilizing the results achieved with
the intervention. Medicated patches and one external splint
are placed. These patches approach uniformly the cutaneous
and subcutaneous tissues of the underlying structures and
stabilize the shape, especially the tip. It is important to apply
them symmetrically without wrinkling the skin. Usually
some are applied on the nasal dorsum, with two longer ones
from the tip to the root [1].
620
Various materials such as metal, plastic materials, and
plaster can constitute the external splint. Ready-made com-
mercial splints are available, but some surgeons prefer to
customize them according to the patient. They are applied on
the dorsum to stabilize the lateral fractures of the nose and
protect it from any external blows. Splints are usually
removed within a week.
The sutures of the columella are removed after 5–7 days
and the alar ones after 10 days; the internal absorbable
sutures fall out by themselves.
11 Postoperative Care
The type, amount, and duration of antibiotic therapy admin-
istered vary depending on the evaluation of the surgeon and
may be modified signs of infection persist.
Normally the initial dose is cephalosporins or beta-lactam
half an hour before the operation, continuing for a variable
period of about 3–7 days.
To reduce the swelling intraoperatively, high-dose ste-
roids may be administered, gradually increasing in the fol-
lowing days.
About 10 days preoperatively and 10 days postopera-
tively, agents that potentially increase bleeding are sus-
pended. In these patients anti-pain therapy is very
important, comprising paracetamol with or without
codeine, combined with other opioids or NSAIDs.
Persistent bleeding and hematoma formation require
reopening the breach and surgical evacuation. Infection
that clinically appears with swelling, redness, pain, and,
in some cases, purulent leakage should be treated with
specific antibiotic therapy. Edema is a typical conse-
quence, for which triamcinolone acetate (10 mg/ml) with
lidocaine can be administered subcutaneously, but must
be applied at depth to avoid skin thinning and
irregularity.
Nasal obstruction may be due to simple presence of
edema or to a postoperative surgical outcome. The adminis-
tration of nasal decongestants solves the problem only if it is
due to inflammation; if the obstruction persists one should
perform a careful clinical examination and, eventually, re-
operate as needed [6, 10, 11].
12 Complications
Rhinoplasty surgery, like any surgical procedure, may have
complications. So as not to undermine the operation out-
comes, rapid identification and treatment of the complica-
tions is necessary. Complications may be divided into three
broad categories: immediate, early, and late.
C. Alfano et al.
Didactically we can classify as immediate, those that
occur within the first 24–48 h; early, those that occur over a
period of 1 month; and late, those at a distance of some
months hence [1].
The immediate complications are bleeding and hematoma
formation. The presence of slight bleeding is normal in the
first hours after surgery, and in most cases resolves without
resorting to surgical maneuvers.
The structures responsible are usually the turbinates,
because of their rich vascularization, and vascular elements
present in the septum. In most cases bleeding can be stopped
by simply raising the patient’s head and applying hemostatic
substances to the tampons previously placed. Sometimes if
bleeding persists it is necessary to remove the tampons and
focally cauterize areas with silver nitrate. The persistence of
bleeding requires anterior packing and, rarely, a posterior
one. Access is rarely required in the operating room; those
who are refractory may require angiographic embolization.
A hematoma is a blood collection that occurs in the sep-
tum and nasal mucosa or between the subcutaneous tissues
and the below osteocartilaginous skeleton. The patient can
manifest pain, runny nose, nasal obstruction and lateral
swelling of the septum, and distortion of the nasal pyramid
shape. The most frequent causes of septum bleeding are
defective suture between mucous and cartilaginous struc-
tures, and the placement of endonasal tampons not large
enough to achieve proper hemostasis [1, 6, 19].
In the case of skin hematoma, the area of greatest concern
is the tip. The reason for bleeding in this case can be an
insufficient approximation of the cutaneous tissues with the
osteocartilaginous planes or an altered blood count.
Hematoma must be treated immediately with drainage of the
collection, since its persistence may cause infection and
retracted scarring.
The loss of cerebrospinal fluid can manifest immediately or
after removal of the tampons, according with the type of dress-
ing. Rhinorrhea and headache are the key symptoms. This can
happen when the cribriform plate of the ethmoid bone is dam-
aged. This situation requires breach repair by endoscopy, in
addition to antibiotic therapy to prevent meningitis.
Other surgical damage includes epiphora, leading to tear
fluid loss due to altered drainage by the lacrimal canaliculi.
If these structures are not anatomically damaged after the
disappearance of the edema postoperatively, the tear fluid
will be completely restored. Alternatively one can place a
silicone tube into the lacrimal system for recanalization.
Among the early complications are infection, edema, and
respiratory failure.
Infection can also occur in the first 24 h but more often
manifests within a week, with redness, pain, and heat on the
region. If it affects the subcutaneous tissue it may progress to
cellulitis, and if the cavities are involved abscesses are a
possible consequence. Usually the abscesses originate from
Basic Rhinoplasty
the tip, the septum, and the dorsum. Infection may be com-
bined with fever. As a complication it is immediately recog-
nized and can be treated with broad-spectrum antibiotic
therapy against gram-positive and gram-negative bacteria. If
there is any secretion, it should be collected for microbiologi-
cal culture.
Case Studies
(a) A 25-year-old female patient. Note the presence
of a highly represented osteocartilaginous hump. In
the lateral view the nasal pyramid hypertrophy marks
a slight mandibular atrophy. (b) Postoperative result.
A slender tip can be appreciated; in the lateral view,
the correction of the pyramid shows how the face has
realized a new balance without intervening on the
lower jaw.
621
Edema is part of the normal evolution of the rhinoplasty,
but becomes a complication when it persists beyond 6 months
to a year. It is secondary to tissue trauma, and manifests
marked swelling of the subcutaneous tissue. In most cases it
resolves by itself; otherwise the affected area can be infil-
trated with a small dose of corticosteroids [1, 6, 11, 16].
(a) A 30-year-old female patient. Presence of a hump
starting from the nasofrontal angle and, in lateral view,
brevity of the lip filter. (b) It is evident that the pyramid has
now a more “endearing” aspect. In the lateral view, even
when smiling, there is absence of any hooking of the tip.
622 C. Alfano et al.

(a) A 23-year-old female patient. Presence

of highly represented osteocartilaginous hump
and brevity of the filter with “gingival smile.”
(a) A 19-year-old female patient. Over-representation (b) Postoperative view. Note the good correction
of all the anatomical units of the nasal pyramid and obtained by hump removal and the nasolabial angle,
shortness of the lip filter are visible on lateral view. and correction of the “gingival smile” with achieve-
Furthermore, viewing from the bottom, deviation of the ment of a more natural look.
septum base is observed. (b) Postoperatively, the bal-
ance of all the volumes of the face is appreciated. In side
view, the “slide” of the pyramid looks natural with
extension of the lip philtrum. Viewed from the bottom,
there is absence of septum base deviation.
Basic Rhinoplasty
(a) A 26-year-old man. Hypertrophy of the entire
nasal pyramid with mandibular hypoplasia; viewing
from the bottom, a square tip and hypertrophy of the
anterior nasal spine is observed. (b) Postoperative
view. Note the hump reduction and the absence of
any pyramidal deviations. In side view, retreat and
correction of the anterior nasal spine is apparent.
It was decided to use part of the nasal bones and
quadrangular cartilage, removed during the previ-
ous hump reduction, as grafts for the mandibular
hypoplasia correction.
References
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Editore, Roma
2. Alfano C et al (1997) Rinoplastica open: nostra esperienza. Atti del
46° Congresso SICPRE, Venezia, pp 135–142
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critical self-evaluations of their noses. Plast Reconstr Surg 98(3):
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con tecnica chiusa: nostra casistica dal 1995 al 1996. Riv Ital Chir
Plast 29(4):285–292
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goes on. Plast Reconstr Surg 99:858–867
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tip rhinoplasty. A perspective of the evolution of surgery of the
nasal tip. Clin Plast Surg 23:245
 Septoplasty and Treatment of Turbinate
Hypertrophy
Andrea Gallo, Giulio Pagliuca, and Salvatore Martellucci
1 Functional Nasal Septal Surgery
Modern surgery of the nasal septum aims at correcting the
deformities of the septum respecting its function (external
nose support, regulation of airflow, mucosa support). From
the first documented surgery of septum correction in the first
half of the nineteenth century, consisting of a perforative
demolition of the obstructive septal area, several authors
(from Chassaignac to Hartmann to Killian and Cottle [1–6],
just to quote some of the most famous names) have gradually
improved their surgery techniques till the arrival of modern
endoscopic correction techniques [7, 8].
From the vast resection of cartilage and bones of the nasal
septum, which often cause functional distortion (air vortex
during respiration, formation of crusts, nasal obstruction)
and aesthetic altering (saddle nose, losing support of the
nose tip or septum perforations) of the nose [9, 10], we
arrived at more conservative techniques based on the preser-
vation (as much as possible) and reconstruction of the differ-
ent septal units. The term septoplasty indeed means a
procedure of removal, reshaping, and repositioning of the
different septal components. The subperichondrial-
periosteum detachment allows one to operate, while preserv-
ing the mucosa and, consequently, the nose physiology.
A proper approach to the functional surgery of the nose
cannot overlook a careful assessment of the patient and the
septum deviation characteristics of the nose.
Cottle identified five distinct areas inside the nose, ascrib-
ing the disorders of nasal respiration to morphological alter-
ing of one or more of those areas.
A. Gallo, MD, PhD (*) • G. Pagliuca, MD, PhD
Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche,
Università di Roma “Sapienza”, Rome, Italy
e-mail: andrea.gallo@uniroma1.it
S. Martellucci, MD
U.O.C. di Otorinolaringoiatria,
Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche,
Università di Roma “Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_44
1.1 Area 1: Vestibular Area (Fig. 1)
It is the most caudal portion of septal cartilage, and it could
be displaced toward the premaxilla or it could be folded. The
septal cartilage is connected with the columella through the
membranous septum, and its displacement could cause a
repositioning of the columella on the middle line. Usually,
the respiration problems are few.
1.2 Area 2: Nasal Valve Area (Fig. 2)
The average angle between the septum and the triangular
cartilage should be between 10° and 15° to ensure a cor-
rect inspiration and expiration. If a traumatic event were
to hit the septum at the valve level, its stabilization in a
faulty position could determine an alteration of the quad-
rangular-triangular ratio with a pronounced nose obstruc-
tion in the inspiration act, which would become worse
under physical effort.
1.3 Area 3: Attic Area (Fig. 3)
It is in a very high position, under the bone vault, far from the
usual direction of airflow. For this reason the rare deforma-
tions of this area are unlikely to cause obstructive symptoms.
1.4 Area 4: The Anterior Half of the Nasal
Cavity (Fig. 4)
This area is delimited laterally by the anterior half of the
nose wall with the corresponding portion of medium and
inferior turbinates and medially by the corresponding part of
septal cartilage. Nasal obstruction is mostly caused by a
deviation of the nasal septum of inborn or post-traumatic
cause. The nasal septum could touch the turbinate mucosa so
as to originate its compression.
625
626 A. Gallo et al.

Fig. 1 Cottle’s area 1: vestibular area Fig. 3 Cottle’s area 3: attic area

Fig. 2 Cottle’s area 2: nasal valve area Fig. 4 Cottle’s area 4: anterior half of nasal cavity

The symptomatology could vary considerably. Usually,

there is a unilateral nasal obstruction and an excessive
counter-lateral permeability with a consequent alteration of
thermoregulation processes, a feeling of too cold air and irri-
tation of the mucosa. There is a possible association with
frontal migraine, more marked on the side of deviation and
algic syndromes of the hemiface.

1.5 Area 5: Turbinate Posterior Area (Fig. 5)

It is composed medially by the posterior portion of the nasal

septum and laterally by the nasal wall with the correspond-
ing turbinate posterior area. Usually, the septum deformities
in this area are a continuation of the septum deviation of the

Fig. 5 Cottle’s area 5: turbinate posterior area

Septoplasty and Treatment of Turbinate Hypertrophy
area 4. There can be retronasal disorders (pain or muffled
hearing) associated with the nasal symptoms, similar to those
described for the deformities of area 4. Anterior rhinoscopy
alone could not be enough to point out a deformity in this
area, whose evaluation should be done through nasal endos-
copy and measurement of nasal resistances (rhinomanome-
try). The functional surgery of the nasal septum aims at
correcting the morphological modifications of Cottle’s areas
that should be seen in a three-dimensional way, such as vol-
umes delimited laterally by nose walls and medially by the
nasal septum. This volume is the one to be altered and is the
one that causes the obstructive symptoms, and it is this same
volume that the surgeon has to make “normal” and func-
tional by correcting its form and size. The nasal septum and
the turbinates are the anatomic structures that could be modi-
fied surgically in order to attain the needed functional results.
The “Maxilla-Premaxilla” approach, proposed by Cottle and
spread in Italy by Sulsenti, represents in our opinion the cho-
sen technique for the correction of all deformities of the sep-
tum, as it guarantees the utmost respect for the nasal
functions.
In this technique, which we describe in the following
pages in all its surgical steps, the incision is limited, and the
mucosa and the support function of the septum toward the
nasal pyramid are preserved.
Usually, the surgery for correction of a nasal septum devi-
ation is made under general anesthesia with orotracheal intu-
bation. Even if it is possible to make the correction of some
limited cartilaginous deformities with local anesthesia, we
suggest limiting this approach to selected cases. The surgeon
has to be on the right side of the patient’s head, while the
assistant stays on the opposite side. The theater nurse with
the service table and the surgical instruments stays at the top
of the patient’s head. It is useful to put the patient in anti-
Trendelenburg position to reduce venostasis and intraopera-
tive bleeding.
The infiltration of vasoconstrictor drugs simplifies the
detachment of the muco-perichondrial layer, allowing easy
identification of the proper dissection plane, so as to have a
bloodless operating field. In this regard, a blend of adrena-
line and naropin could be injected with a thin needle at the
caudal end of the nasal septum until the nasal mucosa has a
whitish color. Additional injections may be made posteriorly
on both sides of the septum. After having injected the infil-
tration drug, it is necessary to wait at least 10 min before the
maximum vasoconstriction effect is reached.
1.6 Hemitransfixion Incision
The columella retractor should be put at 1 cm from the
edge of the septal cartilage and, by tightening the retractor,
it can be moved externally until the surgeon can grab the
627
membrane septum that connects the columella with the
septal cartilage. At this level the retractor should be tight-
ened, and it should swing toward the patient’s left side
downward so as to underline the free margin of the septal
cartilage.
A protection of the nasal ala has to be applied to cover the
cutaneous edge of the nostril and to improve the visualiza-
tion of the operating field. The surgeon incises the septum
mucosa on the right with a scalpel blade 15 upward so as to
be always able to see the scalpel tip and have a bloodless
field. The incision is made on the septum mucosa at 1–2 mm
from its anterior edge (Fig. 6). The perichondrium is
completely dissected through several incisions until direct
contact with the septal cartilage, which appears shiny,
smooth, and bluish, whereas the perichondrium is yellow,
pale, and opaque. Recognizing the subperichondrial plane is
necessary because the detachment of this level allows a
bloodless operating field and a more resistant flap, which
decreases the likelihood of perforations of the nasal septum.
Using a dissector, the surgeon detaches the mucous-peri-
chondrial layer, which covers the right inferior part of the
septal cartilage, till the caudal margin is reached, which
should be marked in all its length. The detachment is carried
out on the left side at a depth of 2 mm without tearing apart
the perichondrium.
1.7 The Left Anterior Tunnel
The surgeon removes the columella retractor and puts a
Killian’s nasal speculum on the surgical incision, continuing
the detachment on the left side, preferably with an aspirating
dissector. The mucous-perichondrial layer is detached from
the quadrangular cartilage surface and the mucous-
periosteum layer is detached from the surface of the vertical
plate of the ethmoid bone. The surgeon creates a left anterior
tunnel, which has the same length of the septal cartilage and
bone (Figs. 7, 8, 9, and 10). At the bottom the tunnel reaches
the premaxillary crests and the vomer furrow, whereas at the
top the detachment can reach the internal wall of the bone
and cartilage vault.
1.8 The Cottle’s Magic Plane
Cottle’s magic plane is a wide horizontal intra-aponeurotic
pouch set in front of the nasal spine and the anterior face
of the maxilla and premaxilla bones that could be created
if it becomes necessary to widen the operating field in
order to get a better visualization. The creation of this
pouch allows a better mobilization of the nasal pyramid
base and the nasal alae. It is made with a curved scissors
with the concave side put toward the surgeon. Performing
628 A. Gallo et al.

Fig. 6 Hemitransfixion incision

Fig. 9 The left anterior tunnel: the detachment plane is between the
perichondrium and the surface of the quadrangular cartilage

Fig. 7 Subperichondrial detachment on the left side of the septum

Fig. 10 The left anterior tunnel: detachment margins

Fig. 8 The left anterior tunnel

Septoplasty and Treatment of Turbinate Hypertrophy 629

a blunt dissection the surgeon detaches the membrane sep-
tum parallel to the columella and behind the medial crura
of the alar cartilages. At this point during the surgery, it is
important to pay attention to not separate the medial crura
of the alar cartilage by a detachment that is too anterior.
Using the same curved scissors, the detachment goes
behind the orbicularis oris muscle and to the front of the
nasal spine. Laterally, the detachment goes from one nasal
ala to the other.
curving side and the detachment starts under the periosteum
with gentle movements and close to the bone so as to detach
the floor of the nasal fossa. He proceeds in the anterior-
posterior direction, keeping a constant contact feeling of the
instrument with the bone until the posterior edge of the hard
palate. The tunnel is made first on the right side and then on
the left side.

1.9 Prespinal Plane

With the help of a Killian’s nasal speculum, the surgeon

visualizes the prespinal space through the hemitransfixion
incision, and with a scalpel blade 15 he cuts or detaches the
prespinal fibers, which adhere to the surface of the cartilage
septum and the nasal spine (Fig. 11). With a Mac Kenty peri-
osteal elevator the surgeon detaches the fibers sticking on the
nasal spine and on the lateral walls, until he can see the
medial portion of the inferior edge of the piriform aperture
(Fig. 12).
The detachment is performed between the perichondrium
and the left side of the quadrangular cartilage by introducing
a dissector through the hemitransfixion incision.

1.10 Inferior Tunnels

With a thin narrow Cottle elevator, curved at the extremities, Fig. 12 The surgeon proceeds with the detachment of the prespinal
fibers of the surface of the cartilage septum and the nasal spine
the surgeon starts a subperiosteal detachment, adhering to
the nasal crest (Fig. 13). The instrument is used by its greater

Fig. 11 With a scalpel blade 15 the surgeon detaches the prespinal

fibers Fig. 13 The right inferior tunnel
630 A. Gallo et al.

1.11 Fourth Tunnel

In those cases where it is necessary to remove the septal car-

tilage or move it completely (push-up technique), the fourth
(right anterior) tunnel may be created with the same proce-
dure as the left anterior tunnel.

1.12 Tunnels Connection

At this stage it becomes necessary to connect the two tun-

nels on the left side (the front tunnel with the inferior one)
by inserting a Killian’s nasal speculum in the left anterior
tunnel and detaching with a Cottle elevator from behind
working forward and from the top to the bottom. The
detachment proceeds easily in the posterior part of the sep-
tal bone, whereas it is more difficult in the front portion
due to the presence of fibrous tissue often adhering to the
surface.

Fig. 14 The picture shows the posterior and inferior chondrotomy (the
1.13 Correction of the Nasal Septum quadrangular cartilage is detached respectively from the surface of the
Deviations vertical lamina of the ethmoid bone and the vomer) and the inferior
vomer osteotomy

Through the creation and connection of the tunnels it is pos-

sible to visualize the entire nasal septum from the vault to the
nasal floor and, thus, perform the necessary operations in
order to correct the cartilage and bone nasal septum devia-
tions. According to the features and position of the septal
deviation, it will be possible to bring it back on its axis
through several surgical operations. Through horizontal or
vertical chondrotomy and osteotomy (Fig. 14), it will be pos-
sible to remove and possibly reshape and reinsert bones and
cartilage fragments so as to restore the normal osteo-cartilage
structure of the nasal septum.
At the end of the operation, the suture of the incision is
made by two absorbable suturing transfixion stitches with
straight or curved needle (Fig. 15). It is necessary to insert
nasal packings in the nostrils, to be kept for 3–5 days. During
this time it is advisable to prescribe a proper antibiotic
therapy.

2 Endoscopic and Video-Assisted Fig. 15 The suture of the hemitransfixion incision has two suturing
Surgery of the Nasal Septum stitches

In the last two decades, functional endoscopic sinus surgery
or FESS has been in widespread use for the treatment of
chronic sinusitis, and subsequently, there are several sur-
geons that use an endoscopic approach even for the correc-
tion of the nasal septum [11, 12]. Endoscopic surgery implies
appropriate surgical instruments and a long learning curve,
but it also has undeniable advantages such as the possibility
of having an excellent visualization of cartilage and bone
surfaces [13, 14].
This kind of surgery generally uses a rigid optic fiber with
an angle of 0° or 30° and a 4-mm-diameter.
The surgery is to be made after a careful assessment of the
patient’s general conditions and the characteristics of his sep-
tal deviations, under general or local anesthesia. An infiltra-
Septoplasty and Treatment of Turbinate Hypertrophy 631

tion with anesthetics or vasoconstrictors is made in order to are performed through the hemitransfixion incision and the
ease the detachment of the mucous-perichondrial layer and septal cartilage is detached from the mucous-perichondrial
have a bloodless surgical field. According to the needs the coat (Fig. 19).
incision could be hemitransfixion as described in Cottle’s sur- The detachment of the mucous-perichondrial and
gery or it could be made over the deviation. In the latter case, mucous-periosteal flap of the posterior part of the nasal sep-
the incision of the mucosa is made a few millimeters before tum could be directly processed with an aspirating dissector
the portion of deviated septum so as to prepare a mucous-peri- under endoscopic visualization. It is possible to effectuate
chondrial flap with inferior hinge. The detachment of the the preparation of the inferior tunnels and the connection
mucous-perichondrial flap is made under endoscopic monitor- between them as during the operation with frontal light
ing. After a septal cartilage incision some millimeters behind (Figs. 20 and 21).
the incision of the mucosa, the surgeon makes a detachment of
the mucous-perichondrial layer in a contralateral position
compared with the previous detachment. The nasal septum is
freed bilaterally from the mucous-perichondrial layer for the
whole area of the deviation. The portion of deviated nasal sep-
tum is removed under endoscopic monitoring after having dis-
sected the nasal septum with endoscopic scissors. The
endoscopic correction of the nasal septum, reserved to very
limited deviations and usually contraindicated in case of
greater deformities of the nasal septum, allows an excellent
visualization of the surgical field and is suitable to make a very
limited detachment of the mucosa with less trauma.
In case of major anterior and/or posterior deviations of
the nasal septum it will still be possible to perform some
steps of Cottle’s septoplasty in nasal endoscopy [15–17]. In
those cases it is also possible to perform the infiltration, the
hemitransfixion incision and the setup of the left anterior
tunnel with the video-assisted technique for education pur-
poses, as previously described. In this case the visualiza-
tion of the surgical field happens through a rigid optic fiber
at 0° supported by a third operator positioned on the sur- Fig. 17 Right hemitransfixion incision at 2 mm from the caudal margin
geon’s right side (Figs. 16, 17, and 18). The anterior tunnels of the quadrangular cartilage

Fig. 16 Infiltration of the nasal septum with a blend of anesthetics and Fig. 18 Preparation of the mucous-perichondrial flap (left anterior tun-
vasoconstrictors nel). (1) Quadrangular cartilage. (2) Mucous-perichondrial flap
632
Fig. 19 Preparation of the left anterior tunnel. (1) Quadrangular carti-
lage. (2) Aspirating dissector
Fig. 20 Preparation of the left inferior tunnel. (1) Quadrangular carti-
lage. (2) Mucous-perichondrial flap. (3) Maxillary crest. (4) Nasal cav-
ity wall. (5) Aspirating dissector
With this technique the nasal septum mucosa, which par-
ticularly tends to tear up, especially near the part of the devi-
ated septum, has a low risk of lesions. Under endoscopic
monitoring it will be possible to process horizontal or verti-
cal chondrotomies or osteotomies and the surgical opera-
tions to correct a deformity of the nasal septum.
3 Turbinate Surgery
The lateral wall of the nose has a quite irregular surface due to
the presence of three or four embossments called conchas or
turbinates. According to their position they are called inferior,
A. Gallo et al.
Fig. 21 Tunnels connection. (1) Quadrangular cartilage. (2) Maxillary
crest. (3) Mucous-perichondrial flap. (4) Nasal cavity wall. (5)
Aspirating dissector
middle, or superior turbinates. In some cases there could be a
fourth couple of turbinates set in a higher position as the previ-
ous turbinates called supreme turbinates. The mucosa of the
nasal fossae is mostly made of respiratory ciliated pseudostrat-
ified columnar epithelium. It is covered with a thin mucous
patina produced by the goblet cells of the superficial epithe-
lium and by the salivary glands. In this layer of mucous we
distinguish a sol phase, which is deeper and fluid, and a gel
phase, which is more sticky and superficial. The movement of
the respiratory epithelium cilia allows the gel phase to flow
more quickly than the sol phase, along paths that lead the
mucus toward the rhinopharynx and then the digestive tract.
This “cleaning” process of the nasal walls is defined mucocili-
ary clearance and it allows the constant removal from the nasal
walls of all impurities or germs inhaled from the external envi-
ronment. In a deeper position from the epithelium coat there is
the chorion, a lamina propria, which reaches the periosteum.
This is made of loose connective tissue, which is rich in elastic
fibers. The most superficial layer of the lamina propria is made
of a rich capillary network and cells designated for the immune
response (lymphocytes, macrophages, plasma cells, mono-
cytes, and mast cells). The intermediate layer has glands that
produce serous mixed mucus, with a high concentration of
enzymes (lysozyme, lactoferrin) with bacteriolytic function.
In the deepest layer of the lamina propria there is a vascular
plexus–nourished sphenopalatine artery and branches of the
anterior ethmoidal artery. From this plexus start several heli-
coidal blood vessels with different anastomoses, which flow
into a rich capillary network. From the capillaries the blood
flows into the venous circulation through cavernous sinusoids,
which have a wall rich in smooth muscle fibers that create a
proper sphincter. Apart from the venous blood, the cavernous
plexus receives also the arterial blood through the several
Septoplasty and Treatment of Turbinate Hypertrophy
arteriovenous anastomoses that originate from the helicoidal
arteries before they form the superficial capillary network. The
muscular tone of the smooth fibers is regulated by the sympa-
thetic nervous system, which determines a condition of con-
traction of the cavernous sinusoids due to the temperature and
the humidity of the inhaled air. This system is responsible for
the thickness of the nasal mucosa, especially at the level of the
inferior turbinates. The secretion-vasomotor function of the
nose has a typical cycle of congestion-decongestion of the
nasal turbinates’ mucosa, which causes a change in the lumen
and the nasal resistance.
The nasal mucosa and the anatomical shape of nasal walls,
apart from ensuring this filtration process, allows a regular
airflow where the inhaled air is properly warmed up and
humidified before it reaches the lower respiratory tract [18].
The surgical techniques suggested for the treatment of tur-
binate hypertrophy (isolated or associated with deviations of
the nasal septum) are several, and their own aim is to reduce
the volume of the inferior turbinates so as to cause a reduction
of the nasal resistances. The necessity of preserving the struc-
tural integrity of the nasal mucosa made it possible to gradu-
ally abandon the most aggressive surgery such as the partial
(turbinotomy) or total (turbinectomy) removal of the inferior
turbinate. The new techniques, safeguarding the integrity of
the turbinate mucosa, ensure a greater respect of the physio-
logic functions and of the anatomy of the nose (mucosa-spar-
ing techniques). Clinical evidence has showed that the
indiscriminate widening of the nasal lumen with partial or
total removal of the turbinates actually does not imply an
improvement in the nasal respiration. The interruption of the
mucociliary clearance and the excessive increase of the nasal
cavities volume result in stagnation of mucus, creation of mal-
odorous crusts and tendency to viral or bacterial infections.
3.1 Turbinoplasty
This term includes a series of surgical techniques on bone
and parenchyma of the turbinate through small mucous inci-
sions. Even if more invasive compared with the techniques of
reduction of the inferior turbinate through the submucosa,
turbinoplasty allows a reshaping of the nasal lumen, causing
minimal trauma of the nasal mucosa. These kinds of opera-
tions are made under total anesthesia and a postsurgical nasal
packing is suggested [19–23].
3.2 Surgical Decongestion
of the Turbinates
This decongestion technique, created and popularized by
Sulsenti, aims at reducing the thickness of the inferior turbi-
nate mucosa through an incision of the mucosa made some
633
millimeters behind the inferior turbinate’s head with an
angled scalpel. The surgeon detaches the soft tissues of the
inferior turbinate in all its length with a dissector or an aspi-
rating dissector. The detachment is displayed close to the
bone surface of the inferior turbinate, being careful not to
tear the mucosa up. A periosteal tunnel will thus be created
in order to remove the surplus erectile tissue with a Weil
nasal forceps or a microdebrider. This technique is used and
is generally associated with a septoplasty under general
anesthesia and foresees a nasal packing [9].
3.3 Volume Reduction of the Inferior
Turbinates Using Radiofrequency (RVT)
This decongestion technique of the inferior turbinates
involves the local release in the mucosa of the inferior
turbinate of low-frequency energy through a needle (mono-
polar) or a couple of parallel needles (bipolar), which causes
tissue damage and a scar reaction resulting in a retraction of
the mucosal surface [24, 25].
The intervention may be performed under local anesthesia
with a topical anesthetic. It does not imply a postsurgical
packing and could be made by nasal endoscopy with a rigid
optic fiber. It is advisable, in our opinion, to make this opera-
tion under endoscopic monitoring, as a great visualization of
the mucous surfaces allows the correct implementation of the
application even in the posterior most part of the turbinates.
For the topical anesthesia, lidocaine at 2 % may be directly
sprayed into the nasal fossae and/or nasal packing may be
soaked in anesthetics and inserted inside the nasal fossae in
contact with the mucosa. The electrode radiofrequency nee-
dle is inserted at the level of the inferior turbinate head and is
pushed in parallel to the turbinate surface for the entire length
of the mucosal thickness. For some seconds the energy is
delivered. In our opinion it is advisable to deliver the energy
in two different steps of 4 s, as patients report more pain when
the application exceeds this period of time. These applica-
tions should be made along the whole lateral wall of the infe-
rior turbinate (whose length is about 7 cm) and in three
different points (head, body, and tail of the inferior turbinate).
Through the terminal needles, for 2–4 mm around the elec-
trode, alternating current is spread in the depth of the submu-
cosa so as to cause ionic excitation at cellular level with
subsequent heat increase in the tissue. The heat is not released
from the terminal but it is generated in the depth of the tissue.
The energy causes a denaturation of proteins and a tissue
damage that, in the cicatrization phase, leads to a secondary
fibrosis and a subsequent volume reduction of the inferior tur-
binate. The highest temperature that the tissue can reach is
between 60 and 90 °C, which is lower than the temperature of
electrocautery or laser decongestion [26]. These techniques
could give mucosal lesions and annoying nasal crusts for
634
several weeks after the intervention. In the volume reduction
of turbinates with radiofrequency, on the contrary, the termi-
nal is put on the mucosa depth, avoiding lesions of the ciliary
carpet and causing less thermal damage.
The volume reduction of inferior turbinates through
radiofrequency is well tolerated by the patient and could be
repeated several times, it causes less pain and does not
require nasal packing [27, 28]. Since the damage of the cov-
ering epithelium is minimal, this kind of surgery does not
cause any alteration in the physiological mechanism of the
nasal mucosa, and it is considered by many authors as the
best treatment for the hypertrophy of the inferior turbinates.
Though several techniques for treating the hypertrophy of
the inferior turbinates have been proposed, there is at present
no general agreement on the gold therapeutic standard. It is
anyway acknowledged that it is not possible to disregard the
turbinates’ mucosal coat (and thus the preservation of the
mucociliary clearance) in order to obtain functional satisfac-
tory results, which could also be as long lasting as possible.
Therefore, submucosal techniques, which have lesser trau-
matic impact on the mucosal surface of the turbinate (“muco-
sal sparing techniques”), are to be preferred to the most
demolitive surgery techniques.
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 Full- and Semi-open Rhinoplasty
H. Holmstrom
A rhinoplasty with or without a transcolumellar incision
will give increased exposure of the structure shaping car-
tilages and bones. It is important to realize that such an
“open rhinoplasty” is just another access technique by
which a more precise reshaping of the nose may be per-
formed than with the closed technique as developed by
Joseph in 1931 [1].
The open technique using a transcolumellar incision was
developed already in 1934 by Rheti and popularized in con-
genital malformations of the nose by Potter in 1954 [2, 3].
In later decades the open technique has slowly gained wide
acceptance by most plastic surgeons to be used on certain
indications and by a few as a technique for all cases because
of the increased visibility of the nasal framework resulting
in a better predictability in its reshaping. Many surgeons
argue, however, that the drawbacks of the open technique,
such as the columellar scar, prolonged nasal swelling and
the most dreaded, columellar flap necrosis, restricts its use
to more difficult cases, especially that of a complex nasal
tip. Semi-open techniques have also been developed, which
expose the cartilaginous pyramid without crossing the col-
umella as in full-open rhinoplasty [4, 5].
1 Columellar Incision
The original transverse incisions were either close to the
nasal tip or at the base of the columella. Most common in
later years are midcolumellar incisions. Anatomically, the
columella has an upper parallel and a lower triangular part.
These two parts may be looked upon as aesthetic subunits,
and the correct incision should be at their junction. Any
straight scar may contract and it may be wise to break the
H. Holmstrom, MD
Department of Plastic Surgery,
Sahlgrenska University Hospital, Gothenburg, Sweden
e-mail: hans.holmstrom@plast.gu.se
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_45
incision by a stair step or by angles. If the columella lacks a
basal triangular portion as in many non-Caucasian noses or
in Binder-like deformities, there is often a need to increase
the columella length by stretching it by implants such as
cartilage struts, and it may be unwise to use a transverse inci-
sion at.
Normally, only an upper columellar flap is needed, which
gives the necessary open access to the tip and dorsum of the
nose, but sometimes an inferior columellar flap will help to
visualize the basal part of the medial crurae, nasal septum,
and anterior nasal spine. In this case, the paramarginal inci-
sions are continued downwards towards the sills of the nos-
trils, preferably before cutting across the columella (Fig. 1).
In case of a hanging columella or an obtuse nasolabial angle,
an inferior flap will make the corrections easier. As men-
tioned before, it may also be possible to avoid the transcolu-
mellar incision altogether by using extended paramarginal
incisions, the semi-open technique, by which all of the carti-
laginous vault may be exteriorized through one of the nos-
trils without distortion and may be corrected under full vision
(Fig. 2). The incisions must be paramarginal i.e. just inside
the nostrils following the caudal borders of the medial cru-
rae. Practically, this is best performed by sliding the skin of
the columella laterally with the thumb and thereby visualiz-
ing the margins of the medial crurae. Similarly, external
pressure on the tip of the nose while everting the nostril mar-
gin with a Joseph hook will visualize the cartilages of the
dome and the lateral crus, and the incisions will follow their
caudal borders (infracartilaginous incisions). In the case of
the semi-open technique, the incisions continue laterally
across the border of the lateral extremity of the lateral crus.
The undermining of the columella is kept close to the peri-
chondrium of the medial crurae to make the flaps as thick as
possible. Over the dome and lateral crurae, the undermining
is more close to the skin to leave fibro-fatty tissue and SMAS
segments intact as is routine in the closed rhinoplasty tech-
nique. In the full-open but not in the semi-open technique
subdermal defatting of the nasal tip and wide alar base resec-
tions may be hazardous [6].
635
636
Fig. 1 The Full-Open Rhinoplasty. Paramarginal incision lines just in
front of the medial crurae. A transcolumellar incision creats an upper,
and sometimes lower, columellar skin flap. The nasal framework will be
well exposed after raising the flaps (below)
2 Indications and Contraindications
As the open and semi-open techniques visualize the carti-
laginous pyramid without distortion, they are indicated in
complex deformities of the nasal tip, especially asymme-
tries. It may be argued that a technique which makes a recon-
struction more exact would be of advantage in all
rhinoplasties. This may be the case for surgeons without
experience in closed techniques, but many straightforward
cases may, however, be treated just as successfully with the
closed techniques, and thereby the drawbacks of the open
H. Holmstrom
techniques may be avoided. The transcolumellar incision
creates a long narrow flap and its survival may be at risk, for
example, in smokers. To a certain extent, meticulous han-
dling and suturing of the columellar incision will provide
optimal healing, but patients may complain of visibility and
notching of the scar, which may be difficult to correct and
must be warned about before surgery. An even more serious
drawback of the open technique is that the increased under-
mining of the nasal tip together with a stop in blood flow
through the columella will result in a prolonged edema of the
tip and in some cases a permanent fibrosis and lack of defini-
tion of the tip. The semi-open technique also includes a wide
undermining of the tip but avoids the columellar incision and
decreases the risk of detrimental edema especially in case of
thick sebaceous skin over the tip of the nose.
In secondary rhinoplasty, especially if the primary surgi-
cal technique is unknown, it may be an advantage to be able
to see exactly the framework of the nose and to select a
proper reconstruction. But again, this should be weighed
against the risk of increased fibrosis when a procedure with
less undermining cases will be safer in many cases.
3 Dissection
The correct subcutaneous plane in the columella is just above
the perichondrium of the anterior edges of the medial alar
cartilages. This plane is easiest to arrive from the paramar-
ginal incisions laterally, and when the undermining is com-
plete the transcolumellar incision is performed. The
dissection is then carried cranially to the root of the nose first
in a subcutaneous plane over the tip and later under the peri-
osteum of the nasal bones in a manner similar to that in
closed rhinoplasty. The advantage of an open rhinoplasty is
now evident as the alar cartilages are fully visualized and
their shaping may be more accurate by resections or aug-
mentations. Often, unexpected irregularities of the alar carti-
lages are detected, which would have been missed using a
closed approach. Also the hump is visualized, making its
resection more exact.
4 Reshaping of the Nasal Framework
The great advantage of the open technique is that the correc-
tions can be made with great precision under direct vision.
This is especially important in dealing with the shape of the
nasal tip but also to some extent in working with the septum
and the hump. The boxy and bifid tip is difficult to correct
with closed techniques even in experienced hands. Excess of
fibro-fatty tissue on and between the alar cartilages must be
removed and interdomal sutures must be placed with great
care, which needs direct vision. Cartilage grafts such as colu-
mellar struts and tip augmentation grafts from the septum or
Full- and Semi-open Rhinoplasty 637

Fig. 2 The Semi-Open Rhinoplasty. The paramarginal incision lines are advanced laterally beyond the lateral crurae as well as medially into the
nostril sill (arrows). The total cartilaginous framework is exteriorized through the right nostril. Sic! The columella is intact (right)

chonca auris will be more precisely placed and fixed by open
suturing. However, it has been shown that tip supporting
grafts is more needed in an open than in a closed rhinoplasty
as this technique results in a greater loss of tip projection,
probably due to larger disruption of ligamentous support and
the increased fibrosis resulting in decreased tip definition [7].
The open technique has reportedly increased the possibil-
ity of using a whole range of sutures to correct the shape of
the nasal tip: transdomal, interdomal, lateral crural mattress,
intercrural, and columellar-septal [8]. The evaluation of the
shape must continuously be made with the skin redraped and
pressed down with fingers as in the concealed technique.
The septal borders are well visualized once the hump has
been removed, and any deviation is easy to correct by repo-
sitioning or resections. The extra mucosal dissection may
also be checked and completed if necessary.
5 Summary
The full-open and semi-open rhinoplasty techniques are
access techniques that all plastic surgeons should be trained
in to be able to use in certain complicated nasal deformities.
Both techniques will, by the increased exposure of the nasal
638
framework, enable the surgeon to obtain an exact analysis
and perform an exact reconstruction of the nose. However, as
there are certain drawbacks, they are not techniques for all
seasons. Closed techniques in skilled hands may give equal,
or in some cases, superior long-term results by avoiding the
scar in the columella and nasal tip fibrosis.
References
1. Joseph J (1931) Nasenplastik und sonstige Gesichtplastik. Kabitzsch,
Leipzig, pp 498–842
2. Rethi A (1929) Über die Korrektiven Operationen der Nasendeformiteten.
Chirurg 1:1103
H. Holmstrom
3. Potter J (1954) Some nasal tip deformities due to alar cartilage
abnormalities. Plast Reconstr Surg 13:358–366
4. Guerrosantos J (1990) Open rhinoplasty without skin-columella
incision. Plast Reconstr Surg 85:955–960
5. Holmstrom H, Luzi F (1996) Open rhinoplasty without transcolu-
mellar incision. Plast Reconstr Surg 97:321–326
6. Rohrich RJ, Mussaffar AR, Gunter JP (2000) Nasal tip blood sup-
ply: confirming the safety of the transcolumellar incision in rhino-
plasty. Plast Reconstr Surg 106:1640–1641
7. Adams WP Jr, Rohrich RJ, Hollier LH, Minoli J, Thornton LK,
Gyimesi J (1999) Anatomic basis and clinical implications for nasal
tip support in open versus closed rhinoplasty. Plast Reconstr Surg
103:255–261, Discussion 262–264; Comment 104: 1571–1573
8. Gruber RP, Wall SH Jr, Kaufman D (2006) Open rhinoplasty: con-
cepts and techniques. In: Mathes SJ (ed) Plastic surgery, 2nd edn.
Saunders Elsevier, Philadelphia, USA, vol 2, pt 1. pp 479–482
 Secondary Rhinoplasty
Ronald P. Gruber, Kamakshi Zeidler, and Drew Davis
1 Introduction
1.1 Definitions
By definition a reoperation of a nose previously operated
upon by a prior surgeon is a secondary rhinoplasty. We distin-
guish this from a “revision” which is a reoperation by the
same surgeon on his/her patient. Usually, the secondary oper-
ation is more extensive than the revision. Revision and sec-
ondary rhinoplasty are done for either complications or
unsatisfactory results or the need for further improvement.
Legally it is essential to distinguish between a (1) complica-
tion and (2) an untoward result and (3) the need for further
improvement. A complication is usually associated with a
fault of the surgeon but not necessarily so. For example, a true
saddle nose deformity is most likely the fault of the surgeon.
On the other hand, a supratip deformity is usually an untow-
ard result – even though more often than not we think it can
be prevented. Seeking “a better result” is done on a satisfac-
tory result when both the surgeon and patient feel that more
can be done to obtain an even greater improvement.
1.2 The Patient
Dealing with the secondary rhinoplasty patient requires
more skill and patience than a primary case. The patients
are often unhappy, are skeptical, and need more reassur-
ance than they did prior to their first surgery. The operation
is often more complicated but not necessarily so. It is
important to acknowledge the patient’s complaints. But
R.P. Gruber, MD (*)
Stanford University, Palo Alto, CA, USA
e-mail: rgrubermd@hotmail.com
K. Zeidler, MD
Private Practice, Zeidler Plastic Surgery, Campbell, CA, USA
D. Davis, MD
Department of Plastic and Reconstructive Surgery, Santa Clara
Valley Medical Center, San Jose, CA, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_46
one must always remember not to be judgmental of the
first surgeon. Untoward and unsatisfactory results are a
part of rhinoplasty. No less than 20 % of rhinoplasty
patients need revision. The nose is an unforgiving part of
the anatomy. Unlike a breast augmentation a 1 mm
discrepancy can easily be noticeable and objectionable.
The very best rhinoplasty surgeons in the world have had
to contend with this fact…. And of course, as Jack Gunter
has always said: “there’s no such thing as a perfect
rhinoplasty.”
1.3 Analysis
One of the best ways to undertake secondary rhinoplasty is to
focus on analysis. Oftentimes, analysis is half the case. The
surgeon cannot make a meaningful correction until the nature
of the anatomic problem has been precisely identified and
the extent of augmentation or reduction has been quantified.
It is considered surgical suicide to head into the operating
room without a plan.
It behooves the surgeon to use imagers (Fig. 1) for preop-
erative planning for each patient. Imagers are widely avail-
able and economical. It is usually possible to come to some
sort of agreement by demonstrating to the patient what you
think should to be done and eliciting their feedback as to
what they think should be done. The patient needs to know
what can and cannot be realistically achieved. In the process
of imaging, the surgeon himself/herself learns what prob-
lems may exist. Sometimes, the process of morphing a result
on the monitor one can be enlightening. Often what may
appear to be the problem when judging the patient sitting in
the examining chair is not the problem as seen by the camera
on the monitor. Conversely, some anatomic problems only
become obvious when on the monitor. Patients with unreal-
istic expectations can be weeded out by this process. In short,
morphing with an imager is a form of mock surgery. It is
helpful to use image morphing in front of the patient at the
time of the initial consult as well as just before taking the
patient to the operating room.
639
640
Fig. 1 Imaging is a key to successful analysis. It is the way to perform
mock surgery
1.4 The Skin
One very important observation of all secondary cases is
the thickness of the patient’s skin. Thin skin, while diffi-
cult to elevate at surgery, allows the surgeon to control the
final result better as the sculpting by the surgeon is more
apparent. Skin that is too thin, however, may show imper-
fections. Thick skin, like a rug lying across a chair, tends
to blunt the sculpted result and produce an ill-defined
result. Both thin- and thick-skinned patients tend to form
variable degrees of fibrosis between the skin and cartilagi-
nous/bony framework. This is less of a problem for thin-
skinned patients because some blunting of the anatomy is
tolerated and is more of a problem in thick-skinned
patients. Therefore, an open approach is relatively contra-
indicated in a thick-skinned patient who requires a reduc-
tion rhinoplasty (Fig. 2). The skin in a reduction
rhinoplasty has to accommodate to a smaller framework
and needs the best blood and lymphatic supply possible.
History of an open rhinoplasty approach does not give
license for the surgeon to perform another open approach.
The need for minimal surgery during the second operation
is still important. Surgical undermining tends to create a
great deal of scar tissue and blunt the desired result.
Therefore, an open approach is acceptable in a thick-
skinned patient undergoing augmentation rhinoplasty.
This approach allows the skin to be expanded by the aug-
mented frame (Fig. 2). One of the worst problems a
R.P. Gruber et al.
a b
c d
Fig. 2 Examples of nasal skin thickness. (a–b) thick skin; (c–d)
medium thick skin
surgeon can encounter is a patient who has formed a great
deal of fibrous tissue as a result of his/her surgery.
Correction of this problem is nearly impossible. Further
resection may lead to more fibrous tissue and a bigger
nose than before the operation.
2 General Surgical Solutions
2.1 Artistry in Rhinoplasty
Rhinoplasty is sculpting with a biological medium (carti-
lage and some bone). As such we need to employ principles
known by artists: copying. It is much easier to copy a beau-
tiful structure than it is to create it from memory.
Commercial artists rely on this concept. Unless you are a
naturally gifted artist, you will find this to be the case. Few
of us can draw a descent picture of a cat from memory, but
even an artistically challenged individual can copy a
reasonable facsimile of a cat from a photo. Consequently,
we recommend the use of an intraoperative model of the
ideal or prototype nasal framework (Fig. 3). It saves one the
effort of memorizing facts (e.g., how much the tip should
be elevated above the dorsum, what the width of the lateral
crus should be, and what the angle of divergence is). For
those who perform a reasonable number of rhinoplasty
cases, it is also helpful to have a video camera in the
Secondary Rhinoplasty
operating room (which gives a profile view of the patient at
all times). Magnifiers and loupes make it difficult to see the
nose from a distance and get the proper perspective. A
close and oblique position to the nose does not allow the
surgeon to have an objective appreciation for things such as
the nasolabial angle. It is not surprising that some surgeons
are perplexed to see that the patient’s nose has nostril expo-
sure the next day or at the time of splint removal. They
neglected to judge that angle accurately when the patient
was in the supine position.
Fig. 3 This autoclavable model of the prototype ideal framework for
the nose makes it easy for the surgeon to perform his/her biological
sculpting. Copying from a model is much easier than memorizing the
angles and relationships between various parts of the tip complex
Fig. 4 Part of our suture algorithm for tip-plasty involves (a) a lateral
crural mattress suture which corrects lateral crus convexity and (b, c) a
hemi-transdomal suture which is a modification of the transdomal
641
2.2 Suture Techniques
Suture techniques are one of the main means by which the
framework is controlled. The many types of suture tech-
niques that apply to the primary rhinoplasty apply equally to
the secondary rhinoplasty although fewer are necessary
because some of them have usually been applied at the first
surgery. Guyuron [17] and Behman [2] have reviewed most
of the common techniques. Daniel [4] has a useful algorithm
that solves most all problems and we have one that deals with
most all problems. Our own suture algorithm [7–13] for tip-
plasty involves four basic sutures: (1) hemi-transdomal, (2)
lateral crural mattress suture, (3) interdomal suture, and (4)
columella-septal suture (Fig. 4). The hemi-transdomal suture
[1] is a variation of the transdomal suture that narrows the
dome. It is placed at the cephalic end of the dome so that it
everts the caudal rim and prevents rim collapse or concave
rims. The hemi-transdomal suture minimizes the need to use
rim grafts which are often used to maintain a straight nostril
rim or prevent concave rims. The lateral crural mattress
suture removes any residual convexity of the lateral crus.
One, two, or even three such sutures will flatten out the lat-
eral crus and make it strong. This is especially useful in sec-
ondary cases because the lateral crura are often weak from
the first surgery with residual convexity. The interdomal
suture brings the domes together and provides a small
amount of tip rigidity and symmetry. The columella-septal
suture secures the tip to the caudal septum. One can adjust
the height to some degree with this suture although it is not a
substitute for the columellar strut. All of these suture tech-
niques require either a 5-0 nylon or PDS. If one is certain
suture. It narrows only the cephalic end of the dome and by so doing
everts the lateral crus to minimize problems with collapsed rims
642 R.P. Gruber et al.

there is good soft tissue coverage, a permanent suture such as

Fig. 5 The universal horizontal mattress suture corrects convexities of
strip cartilages
nylon is a reasonable choice.
The universal horizontal mattress suture [8, 9] is a suture
that can be applied to any unwanted convex or concave carti-
laginous structure of the nose in a secondary rhinoplasty.
A short learning curve is necessary because if the gap
between purchases is too little, no effect results, but if the
gap between purchases is too large, the cartilage will buckle
(Figs. 5, 6, 7, and 8). Our studies [8, 9] have shown that one
suture can increase the strength of the cartilage by approxi-
mately 35 %, whereas scoring the cartilage to achieve the
same degree of correction can weaken the cartilage by as
much as 50 % (Fig. 8). The lateral crural mattress suture is
the most obvious example. However, the universal horizontal
mattress suture is also useful for wanted curvatures of the
septal L-shaped struts (Fig. 9). A horizontal mattress suture
can reduce the collapsed hyperconvexity of upper lateral car-
tilages (the so-called butterfly suture). Ear cartilage is much
more usable when it is straightened and stiffened with this

Fig. 6 When the spacing between bites is approximately 6 mm, most of the convexity is removed. More than one such suture may be needed

Fig. 7 If the spacing between bites is too small, no effect is seen; if the spacing between the bites is too large, buckling occurs
Secondary Rhinoplasty 643

particular suture. When the concha cymba is removed from

behind the ear, it is split down the middle, pinned to a sili-
cone block, concave side down. A 5-0 PDS horizontal mat-
tress suture is applied at each end of the cymba to straighten
it and stiffen it. Such a suture-reinforced graft makes a good
columellar strut and can even replace the entire lateral crus if
it is missing (Figs. 9, 10, 11, 12, and 13).

2.3 Grafts and Synthetics

Most secondary rhinoplasties demand grafts to either replace Fig. 10 Horizontal mattress sutures can remove most of the curvature
missing cartilage that has been excessively removed or pro- of the horizontal component of the L-shaped septal strut. Scoring is still
the first option, however. The concept that a horizontal mattress suture
vide support for weak structures. Septal cartilage is pre- can reduce convexity is emphasized in this example where it is applied
ferred. However, it is usually unavailable in sufficient over the superficial surface of collapsed upper lateral cartilages
quantities. Therefore, either the ear or rib is required. For
small amounts of cartilage, we prefer ear cartilage. Since it
can be straightened and stiffened as described above, it is
useful for almost every situation where septal cartilage
would ordinarily be used. However, when large amounts of

7
Biplanar modulus (Mpa)

6
5
4
3
2 Increases
Decreases
by
1 by
35%
48% Fig. 11 A 4-0 PDS suture applied from one upper lateral cartilage to
0 the other opens up the internal nasal valve. It does not preclude the
No points With points Cartilage incision need for spreader grafts and flaps, however, which are the main means
of maintaining internal valve integrity
Fig. 8 A single universal horizontal mattress suture can increase the
strength of cartilage by 35 %. Scoring the cartilage to achieve the same
degree of straightness can reduce the cartilage strength by 50 %

Fig. 9 Horizontal mattress sutures can remove most of the curvature of the vertical component of the L-shaped septal strut
644
cartilage are required, we prefer the fifth rib that is accessible
from an inframammary incision.
Cartilage does not need to be solid in order to reconstruct
noses. Diced cartilage has a vital role especially if it is
wrapped in a substance like fascia to give it shape. This
technique was developed primarily for dorsal augmentation
by Daniel [5]. Erol [6] demonstrated that diced cartilage in a
Surgicel wrapping could be useful. However, we have
remained with fascia to avoid the possibility of absorption
due to the slight toxic effect of Surgicel. The cartilage is cut
into small bits approximately 1 mm in size and placed in a
blanket of fascia (on a silicone block). The fascia is simply
Fig. 12 The ear is a great source of donor cartilage. This concha
cavum/cymba graft is applied to a silicone block where it will be
divided into two units: cymba and cavum. As individual units they are
easily straightened with sutures and made into usable units of cartilage
to reconstruct various parts of the secondary nose
Fig. 13 The concha cymba from the ear is split down the middle. A 5-0 PDS horizontal mattress suture is applied to each end so as to straighten
it and stiffen it. It becomes a good unit one that is useable for a columellar strut or replacing much of the lateral crus
R.P. Gruber et al.
folded over and secured with a 5-0 plain catgut suture. It is
helpful to have applied a silicone sizer in the patient’s dor-
sum to get an idea as to how long and thick to make the
diced cartilage-fascia (DCF) graft (Figs. 14, 15, 16, 17, 18,
and 19).
One option we do consider for reconstruction in second-
ary cases is the use of irradiated allograft rib cartilage [20].
This can be useful when the patient is resistant to harvesting
autogenous material. The main problem with allograft, of
course, is the potential for absorption. Although some reports
of long-term survival exist [3–10], one must be prepared for
absorption approximately 10 years postoperatively. An
option we never consider for secondary rhinoplasty is the use
of implants of any material. The failure rate, and the risk of
skin necrosis, is extremely high. Complications from
implants are much more difficult to correct and therefore are
not used.
2.4 Soft Tissue Fillers
The tissues of many secondary cases are thin particularly the
dorsum. Cartilage grafts under such tissue often leave visible
edges. Therefore, a soft tissue filler is preferable. The dermis
is certainly one choice. Prior to harvesting ear cartilage, an
ellipse of the skin is deepithelized behind the ear and the
soft tissue is harvested. Although it is not a large quantity of
dermafat tissue, it is often adequate. For larger quantities, the
suprapubic dermis is harvested, but one must avoid hair fol-
licles. Fascia (deep temporalis) is another good choice of soft
tissue filler. It is particularly useful as a one-layered cover for
Secondary Rhinoplasty 645

Fig. 16 The silicone sizer is applied to the surface of the tip to see if it
is the appropriate size. It is then applied internally to note the same
Fig. 14 The deep temporalis fascia is harvested using a vertical inci- thing
sion beginning at the root of the ear

Fig. 17 Cartilage of any type is diced into 1 mm sizes and placed in the
deep temporalis fascia. It is easiest to work on the cartilage on a silicone
block with pins to stabilize the fascia
Fig. 15 Silicone dorsal nasal sizers are helpful to sculpt a dorsal graft
when doing secondary rhinoplasty
646
Fig. 18 The fascia is rolled over like making a cigarette and sutured
down one side with a 5-0 plain catgut. The sizer acts as a model to
determine the width and length of the graft
Fig. 19 The diced cartilage-fascia (DCF) graft is lying on the dorsal
surface of the nose
the tip cartilages when the overlying skin is unusually thin
(Figs. 20 and 21). One important caveat is that the temporalis
fascia can thicken to 3× its original thickness during the first
week postop. Therefore, it needs to be sutured in place to
R.P. Gruber et al.
Fig. 20 The schematic demonstrates how a one-layered graft, e.g., the
fascia or dermis, is applied to the entire surface of the tip cartilages
whose overlying skin is exceptionally thin
TFLG TFG TFLG TFG
EXTENSION THICKNESS
Fig. 21 A temporalis fascia graft (TFG) will demonstrate a thickness
increase of up to threefold during the first week postop if not sutured
down. A tensor fascia lata graft (TFLG) on the other hand does not
experience that kind of contraction and thickening (Courtesy of
Indorewala, S. Dimensional stability of the free fascia grafts: an animal
experiment. Laryngoscope 2002; 112:727)
prevent that from happening. Fat is an alternative soft tissue
filler especially when very small quantities are needed.
However, the acceptance of a fat graft is somewhat unpre-
dictable, and the patient should be forewarned of that fact.
Some patients experience problems early after their sur-
gery due either to absorption of autogenous material placed
in the nose or a failure to fully correct the deformity. These
patients may have small depressions. Rather than waiting
until the 8–12-month period has passed when they will
receive a permanent filler, it is often useful to give the patient
a temporary filler such as a collagen or hyaluronic acid prod-
uct. Doing so will relieve the patient’s anxiety during the
healing phase and “buy time” until a more permanent solu-
tion can be provided.
Secondary Rhinoplasty
3 Specific Problems
3.1 Broad, Bulbous, Round Tip (Fig. 22)
One of the most common frustrating secondary noses is the
broad, bulbous, or round tip. Patients complain about this
most often and most vigorously. Fortunately, there are some
Fig. 22 This patient is a good example of a broad tip problem. She
exhibited a broad tip, supratip deformity, and radix deficiency. Because of
the very thick skin, it was decided to use a closed approach. The tip carti-
lages were delivered. The patient received cephalic trim of the lateral crus
647
good solutions. It is important to decide whether to use the
open or closed approach for the reasons mentioned above.
Most of the time the cephalic part of the lateral crus has been
resected at the first surgery. In fact, too much has often been
removed. The first goal is getting to the tip pathology. In the
open approach careful elevation of the flap is necessary. In
the closed approach delivery of the tip cartilages with an
along with interdomal and lateral crural mattress sutures (5-0 PDS).
A radix graft from the septum was used and the caudal septum was short-
ened. A lateral osteotomy was also performed
648
LARGE MEDIUM SMALL
Fig. 23 Tip graft sizers are made of silicone. They come in three sizes
Fig. 24 This schematic demonstrates the shape of an “anatomic tip
graft” which simulates the surface of the middle crura and domes.
Usually, a support graft (appearing as a block of cartilage) is placed
deep to the tip graft in order to enhance the effect of tip augmentation
Fig. 25 The sizer is held in place to the existing tip complex with a needle. When the appropriate size is chosen, it is placed on the donor cartilage
and used as a cookie cutter-like device to carve a tip graft
R.P. Gruber et al.
intercartilaginous and marginal incision is usually needed.
The second goal is to establish a lateral crus that is approxi-
mately 5–6 mm wide and render it straight. Usually, suture
techniques as described above will convert the existing tip
framework into something that is more normal and stronger.
Some secondary noses simply do not warrant the extensive
dissection associated with the closed method of tip delivery
or the open approach. These cases are benefitted by cephalic
resection of the lateral crus alone. This is done by way of an
intracartilaginous incision. All the cartilage (of the lateral
crus) cephalic to the incision is removed. The decision is
guided by what the minimal surgery is necessary to achieve
the goal. Figure 22 shows a good example of a broad tip
problem. The patient exhibited a broad tip, supratip defor-
mity, and radix deficiency. Because of the very thick skin, it
was decided to use a closed approach. The tip cartilages were
delivered. The patient received cephalic trim of the lateral
crus along with interdomal and lateral crural mattress sutures
(5-0 PDS). A radix graft from the septum was used and the
caudal septum was shortened. A lateral osteotomy was also
performed.
3.2 Deficient Tip (Figs. 23, 24, 25, 26, 27, 28,
and 29)
The tip can be deficient (underprojected) either because the
infratip lobule is small or the columella is short or both.
When the tip is deficient, a tip graft is in order [9]; when the
columella is short, a columellar strut is in order; if both are
deficient, both grafts are used. Deficient tips benefit enor-
mously from a tip graft because the tip graft provides
structure and definition. We prefer the “anatomic tip
Secondary Rhinoplasty
graft [9].” Whether via the open or closed approach, the graft
has a shape that simulates the normal surface anatomy of the
middle crus and domes. Septal cartilage is ideal although it
needs to be scored slightly to avoid a tombstone effect. The
concha cavum makes an excellent tip graft because it has just
the right amount of curvature and requires no scoring and is
almost always available. More often than not, additional tip
projection is needed and is provided by a “support graft”
which is a two- or three-layered graft that is placed deep to
the tip graft for three purposes: (1) provide more projection,
(2) immobilize the tip graft, and (3) fill the dead space deep
to the tip graft (Figs. 23, 24, 25, 26, and 27). Figure 28 shows
Fig. 26 The cartilaginous tip graft itself is pinned to the existing tip
complex to see what the best location for it is
Fig. 27 After securing the posterior end of the tip graft to the existing tip complex, a support graft (in this case only a one-layered graft) is applied
to the deep side of the tip graft. Doing so helps secure the tip graft at the proper angle and fill the dead space
649
a good example of a patient with a deficient tip problem. The
patient exhibited a narrow overresected tip, an inverted V
deformity, and an alar retraction. At surgery, through an open
approach, the tip cartilages had to be separated and an inter-
domal graft put between them. An anatomic tip graft was
laid on the surface (the ear acting as donor) and spreader
grafts were inserted. Small rim grafts were also required. She
also received a dermis graft to augment the lips.
3.3 Overprojected Tip
In the secondary nose an overprojected tip can be due to a
large infratip lobule, long lateral crura, or both. For small
overprojection it is often possible to simply use a deep trans-
fixion incision that allows the tip to drop. If the infratip lob-
ule is large, however (best seen on basal view), it may be
necessary to transect the dome and create a new dome by
folding over the lateral crus and holding it in place with
sutures. For those patients who have marked overprojection
not associated with a large infratip lobule, the problem is
probably with long lateral crura. In that case, a section of
lateral crus is resected at the very posterior end.
3.4 Pinched Tip/Concave Rims
Secondary noses often exhibit pinched or collapsed rims.
Some part of the lateral crus is either weak or absent causing
the collapse. Patients not only complain of the appearance but
also of inspiratory airway obstruction. Restoring the integrity
of the lateral crus is the goal. In many cases a lateral crural
650 R.P. Gruber et al.

Fig. 28 This patient is a good

example of a deficient tip problem.
The patient exhibited a narrow
overresected tip, an inverted V
deformity, and an alar retraction. At
surgery, through an open approach,
the tip cartilages had to be separated
and an interdomal graft put between
them. An anatomic tip graft was laid
on the surface (the ear acting as
donor) and spreader grafts were
inserted. Small rim grafts were also
required. She also received a dermis
graft to augment the lips
Secondary Rhinoplasty
strut as described by Gunter [16] is the solution. A small piece
of thin cartilage usually 3–4 × 15–20 mm in size placed just
deep to the cephalic edge of the existing lateral crus will pro-
vide structural integrity and restore aesthetic appearance. If
the problem is small, a simpler procedure is the use of the alar
rim contour graft as described by Rohrich et al. [19]. For
minor problems associated with concave rims, suture tech-
niques also work. By placing one or two 5-0 PDS horizontal
mattress sutures on the convex side of a concave cartilage, the
rim can often become straight and stiff.
3.5 Thin-Skinned Tip
Thin-skinned noses have the advantage that the surgeon
can show off his/her sculpting skills and acquire definition
and great detail. It has the disadvantage, however, that any
imperfections can be seen through the thin skin. Any
small changes of cartilage warping or absorption or shift-
ing can show through the thin skin and mar the result. One
of the best padding is fascia. A one-layered sheet of the
deep temporalis fascia can be enormously helpful in cor-
recting the thin-skinned secondary rhinoplasty patient.
Figures 29, 30, and 31 demonstrate a patient whose thin
skin adversely affected her result. However, a one-layered
fascia graft placed over the entire tip framework softened
the result.
3.6 Collapsed Nasal Bones
Collapsed nasal bones can be an exceedingly difficult prob-
lem to correct in secondary noses. Outfracturing the bones
often fails because the natural tendency of the bones postop
is to collapse medially. Packing the nose to keep the bones in
an outward position is often ineffective. One of the best and
easiest solutions is to simply augment the side of the nasal
bone that is collapsed. However, the autogenous material
must be soft like the dermis or fascia because the skin overly-
ing the nasal bone is exceedingly thin and shows the carti-
lage graft. A single layer of fascia that is harvested from the
temporalis region is our favorite choice (Figs. 32 and 33). It
must be tied down somehow to prevent contraction and
thickening as mentioned above.
3.7 Crooked Nose (Figs. 34, 35, 36, 37, 38, 39,
40, and 41)
The crooked nose was one of the greatest challenges in sec-
ondary rhinoplasty. However, modern techniques have reduced
it to a relatively simple problem. It is important to recognize,
651
however, that crookedness is not only due to the septum. The
upper lateral cartilages and lower lateral cartilages (tip) are
often crooked too. The bones may be crooked as well. The
task of unraveling the nose and its part begins with an open
approach. All the maneuvers to be described can be done with
a closed approach but are exceptionally difficult for obvious
reasons. The upper lateral cartilages are released from the dor-
sal septum. The mucoperichondrium is elevated bilaterally
from the entire cartilaginous septum and parts of the bony eth-
moid. The vomerine ridge is spared from this dissection if at
all possible because it is tedious and perforation is likely. The
cartilaginous septum is converted into an L-shaped strut by
removing the central component. In many secondary cases
this will have already been done. If so, it is only necessary to
free the mucoperichondrium from the existing L-shaped strut.
The posterior aspect of the vertical component is released
from the anterior nasal spine. The horizontal component is
scored once or twice at the point of maximum curvature.
Multiple scorings work well in the hands of an expert, but for
many the end result may be a severely weakened and collaps-
ing septum. If the vertical component is curved, a cartilage
graft may be applied as a batten. Alternatively horizontal mat-
tress sutures work well as described above. The horizontal
component can be reinforced with horizontal mattress sutures
too even if scoring is done. The upper lateral cartilages and
septum are held in a midline position while a needle pierces all
three structures. Sutures (5-0 PDS) (sometimes called clock-
ing sutures) are used to hold all three structures together. If the
middle 1/3 of the nose is narrow to palpation, spreader grafts
are placed between the upper lateral cartilage and septum
before suturing it to the septum. Finally, a “frenulum” suture is
used to maintain the caudal septum midline. It is a 4-0 Vicryl
or Dexon that begins at the frenulum and picks up the caudal
septum (2 bites) and is then passed back to the frenulum where
the knot is tied.
On occasion the bones themselves will be crooked. Often
one nasal bone will be broader than the other, necessitating a
combination of medial oblique osteotomy and lateral oste-
otomy to bring the abnormal nasal bone into a more normal
position. On rare occasion the bony septum is so crooked
that it is necessary to place an osteotome between it and an
adjacent bone to infracture the bony septum back to the mid-
line. Most of the time crookedness of the bony septum is well
tolerated. The most important aspect is the nasal bones, not
the bony septum between them.
A crooked tip may have one lateral crus longer or shorter
than the other. The longer crus requires an excision of a small
piece of cartilage from its posterior end (with suture repair)
in order that the tripod effect of the tip complex is balanced
and equal. When there is crookedness of the medial/medial
crura, the easiest thing to do is to place a columellar strut
between them to force them into a straighter alignment.
652 R.P. Gruber et al.

Fig. 29 (a, b) Pre- and postoperative frontal views of a secondary rhi- with thin skin that shows many irregularities. (e, f) Pre- and postopera-
noplasty patient with thin skin that shows many irregularities. (c, d) tive side views of a secondary rhinoplasty patient with thin skin that
Pre- and postoperative basal views of a secondary rhinoplasty patient shows many irregularities
Secondary Rhinoplasty 653

Fig. 30 Gunter diagram indicating the use of fascia for the tip and dorsum to improve the thin skin condition

Fig. 31 The deep temporalis

fascia and its application to the
surface of the tip complex
(sutured in place)
654 R.P. Gruber et al.

Fig. 32 Pre- and postoperative

views of a patient with collapsed
or overly narrowed nasal bones
that was corrected with a
one-layered deep temporalis
fascia

Fig. 33 Schematic demonstrating the need to tie down the graft so as

to avoid contraction and thickening

Fig. 34 Release of upper lateral cartilages and elevation of the muco-

perichondrium as a first step for septoplasty
Secondary Rhinoplasty 655

Fig. 37 The vertical component of the L-shaped strut is released from

the vomerine groove so that corrections to its curvature can be made

Fig. 35 Tip cartilages retracted out of the way and further elevation of
the mucoperichondrium off the septal cartilage

Fig. 38 The horizontal component of the L-shaped strut is straight-

ened primarily by one or two scores on the concave side

Fig. 36 An excellent view is provided by the open approach so that

scoring with a scalpel can be extremely precise
656
Fig. 39 The curvature of the vertical component is corrected by apply-
ing a universal horizontal mattress suture to the convex side. More than
one such suture may be necessary. A 4-0 PDS suture is the best type to
use
R.P. Gruber et al.
The septal mucoperichondrium is put back with through
and through quilting sutures (4-0 plain). Doyle splints are
applied and kept in place until the plaster splint is removed
6 days later. Figures 42, 43, and 44 show a good example of
a patient with crooked nose who had a prior septoplasty for
that problem. At surgery an open approach was used. Most
of the septum was intact. What was left was converted to an
L-shaped strut which was then scored, sutured with horizon-
tal mattress sutures, and secured to the upper lateral carti-
lages for support. The vertical component of the L-shaped
strut was secured in the midline with a frenulum suture. The
patient also received a small humpectomy and spreader flaps.
A columellar strut from ear cartilage helped created tip sym-
metry. The tip also required lateral crural mattress sutures
and interdomal sutures, and a small tip graft was necessary.
Finally, a medial oblique osteotomy was performed. In addi-
tion he received a submentoplasty.
3.8 Short Nose (Figs. 45, 46, 47, 48, and 49)
The short nose is used to be one of the most difficult cases to
correct. Here, too, modern techniques have made this prob-
lem much less formidable. The algorithm we employ today
is the one introduced over a decade ago [14, 15] and has not
changed in any significant way. Through an open approach
(which is almost a must), the upper lateral cartilages are
released from the dorsal septum. Any available septal carti-
lage is harvested for a septal extension graft. If none is
available, the concha cavum will work but is somewhat
thick. A double hook is placed on the tip cartilages and
pulled caudally. After infiltrating the vestibular skin of the
lateral crus, a releasing incision is made between the upper
lateral cartilage and lateral crus. Small scissors are used to
expand the gap between these two cartilages which length-
ens the side wall of the nose. The septal extension graft is
applied either on the horizontal or vertical component of the
L-shaped strut to maintain the tip cartilages in a caudally
displaced location. If the gap between the upper lateral carti-
lage and lateral crus is significant, an intercartilaginous graft
[18] is placed between the two and is sutured in place. Septal
cartilage is ideal as it is thin and will not produce unneces-
sary thickening. Figures 50, 51, 52, and 53 show a good
example of a patient with a secondary short nose problem.
She had a silicone implant at the first surgery and still had a
severely short nose. At surgery the implant was removed. A
rib graft was required to make a dorsal graft, a columellar
strut, and a septal extension graft. Ear grafts were used for
the tip graft.
Secondary Rhinoplasty 657

Fig. 40 A “frenulum” suture (4-0 Vicryl or Dexon) is passed from the frenulum to the caudal septum (2 bites) and back to the frenulum where the
knot is tied. It keeps the septum straight

Fig. 41 The dorsal septum even after scoring may be slightly crooked and can be held straight by first passing a needle through both upper lateral
cartilages and septum. Then a suture (“clocking suture”) is passed from the upper lateral cartilage to the septum to hold the septum in place
658 R.P. Gruber et al.

Fig. 42 Pre- and postoperative

frontal views of a patient with a
crooked nose. Most of the
septum was intact. What was left
was converted to an L-shaped
strut which was then scored,
sutured with horizontal mattress
sutures, and secured to the upper
lateral cartilages for support. The
vertical component of the
L-shaped strut was secured in the
midline with a frenulum suture.
The patient also received a small
humpectomy and spreader flaps.
A columellar strut from ear
cartilage helped created tip
symmetry. The tip also required
lateral crural mattress sutures
and interdomal sutures, and a
small tip graft was necessary.
Finally, a medial oblique
osteotomy was performed

Fig. 43 Pre- and postoperative

side views of a patient with a
crooked nose
Secondary Rhinoplasty 659

Fig. 44 Pre- and postoperative

basal views of a patient with a
crooked nose

Fig. 45 Schematic of elevation of the mucoperichondrium as a first

step to correcting the short nose
Fig. 46 A gap is created between the upper lateral cartilage and lateral
crus, keeping the lining intact. This maneuver lengthens the side wall of
the nose and may require an intercartilaginous graft to fill the gap
660 R.P. Gruber et al.

Fig. 49 When necessary an intercartilaginous graft is applied to the

gap created between the upper lateral cartilage and lateral crus to main-
tain length of the side wall of the nose

Fig. 47 A batten (septal extension graft) is applied to the dorsal sep-

tum to lengthen the nose

Fig. 48 The batten can be applied to the vertical component of the

L-shaped strut just as well
Secondary Rhinoplasty 661

Fig. 50 Pre- and postoperative

frontal views of a patient with a
short nose

Fig. 51 Pre- and postoperative

side views of a patient with a
short nose
662 R.P. Gruber et al.

Fig. 52 Pre- and postoperative basal views of a patient with a short nose

Fig. 53 Schematic figure demonstrating that the patient with a short nose needed a dorsal graft columellar strut and septal extension graft of rib
origin. The tip graft was of ear origin. The silicone implant was removed
Secondary Rhinoplasty 663

3.9 Broad Nasal Base (Figs. 54, 55, 56, 57,
58, and 59)
Some secondary noses still have a broad nasal base despite
having received a nasal base excision. In some cases further
nasal base excision may help. But in many others, further
skin removal will either make the nostrils stenotic or the ala
so small that they appear unnatural.
One solution is to perform an alar base release and secure
the alae medially with an interalar suture [19]. This maneuver
is particular useful in those patients who have a vertically ori-
ented alar axis (parenthesis alae). Further narrowing at the alar
alone has the potential in those patients to make the alae
assume a bowling pin appearance. By mobilizing the entire ala
(including the cephalic aspect), that problem can be mini-
mized. Before executing the procedure one should perform the
pinch test. The examiner should bring the alae together with
two fingers to see if the nasolabial angle becomes more obtuse
than desired. If so, a limit should be placed on how much alar
release is performed, or one should plan to resect some of the
anterior septal spine region to prevent an abnormally obtuse
nasolabial angle postop.
An incision is made at the junction of the ala and nos-
tril sil. Through this incision or a separate buccal sulcus

Fig. 54 The nose has an alar axis. When it points straight down and the two axes are parallel, the patient is said to have parentheses alae. It is a
potential problem in that if an alar base excision is performed, the axes may turn inward giving the patient a bowling pin deformity

Fig. 55 The pinch test is done to be sure that bringing the alar together does not cause an abnormal nasolabial angle when an alar release and
interalar suture procedure is performed
664 R.P. Gruber et al.

Fig. 56 An incision is made at the junction of the ala and nostril sil. An
elevator is used to release the ala from the maxilla and pyriform groove
Fig. 58 Interalar sutures (3-0 nylon) are placed from the dermis of one
ala to that of the other

Fig. 59 An alternative means of freeing the ala from its maxillary and
nasal vault attachments is to use a buccal sulcus incision (similar to that
used for some lateral osteotomy techniques)

Fig. 57 When performing an alar release, it is often necessary to ele-

vate the periosteum off the nasal vault
Secondary Rhinoplasty
incision (as we prefer), a Joseph periosteal elevator is
used to free the soft tissue off the maxilla. The surgeon is
also releasing the recently described pyriform ligament
by Rohrich et al. [18] sweeping the instrument along the
horizontal pyriform rim. If necessary, the release can
extend into the floor of the nasal vault. A pair of 3-0
nylon interalar sutures is then passed from the dermis of
Fig. 60 (a, b) Pre- and postoperative frontal views of a patient who
received alar base excision and thinning of the alar wall but incomplete
correction of the broad nasal base. (c, d) Pre- and postoperative basal
665
one ala to that of the other. Care must be taken to avoid
placing the large suture knots too close to the skin sur-
face. The patient shown in Figs. 60, 61, and 62 had a
prior nasal base excision but not enough improvement.
Further excision would have only distorted her alae and
possibly nostrils. Alar release was performed to get fur-
ther improvement.
views of a patient who received alar base excision and thinning of the
alar wall but incomplete correction of the broad nasal base
666 R.P. Gruber et al.

Fig. 61 Schematic figure showing maneuvers performed to make the nose smaller including alar base excision, alar wall thinning, and cephalic
trim of the lateral crus

Fig. 62 (a, b) Pre- and postoperative frontal view of the same patient view of the same patient who received further reduction of nasal base
who received further reduction of nasal base width using the alar release width using the alar release method including interalar sutures
method including interalar sutures. (c, d) Pre- and postoperative basal
Secondary Rhinoplasty 667

References 11. Gruber RP, Nahai F, Bogdan MA, Friedman GD (2005) Changing
the convexity and concavity of nasal cartilages and cartilage grafts
with horizontal mattress sutures: part I. Experimental results. Plast
1. Amarjit D, Hsu C, Gruber RP (2010) The hemi-transdomal suture.
Reconstr Surg 115(2):589–594
Ann Plast Surg 64(6):708–712
12. Gruber RP, Nahai F, Bogdan MA, Friedman GD (2005) Changing
2. Behmand RA, Ghavami A, Guyuron B (2003) Nasal tip sutures part
the convexity and concavity of nasal cartilages and cartilage grafts
I: the evolution. Plast Reconstr Surg 112(4):1125–1129
with horizontal mattress sutures: part II. Clinical results. Plast
3. Constantian M (1999) Elaboration of an alternative segmental
Reconstr Surg 115(2):595–606
cartilage-sparing tip graft technique: experience in 405 cases. Plast
13. Gruber RP, Weintraub J, Pomerantz J (2008) Suture techniques for
Reconstr Surg 103:237–253
the nasal tip. Aesthet Surg J 28(1):92–100
4. Daniel RK (2008) Diced cartilage grafts in rhinoplasty surgery:
14. Gruber RP (1993) Lengthening the short nose. Plast Reconstr Surg
current techniques and applications. Plast Reconstr Surg 122(6):
91(7):1252–1258
1883–1891
15. Gruber RP (1996) The short nose. Clin Plast Surg 23(2):297–313
5. Daniel RK (1999) Rhinoplasty: a simplified, three-stitch, open tip
16. Gunter JP, Friedman RM (1997) Lateral crural strut graft: technique
suture technique. Part II: secondary rhinoplasty. Plast Reconstr
and clinical applications in rhinoplasty. Plast Reconstr Surg
Surg 103(5):1503–1512
99(4):943–952
6. Erol OO (2000) The Turkish delight: a pliable graft for rhinoplasty.
17. Guyuron B, Behmand RA (2003) Nasal tip sutures part II: the inter-
Plast Reconstr Surg 105(6):2229–2241
plays. Plast Reconstr Surg 112(4):1130–1145
7. Gruber RP, Freeman MB, Hsu C, Elyassnia D, Reddy V (2009)
18. Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE (2008) The pyri-
Nasal base reduction: a treatment algorithm including alar release
form ligament. Plast Reconstr Surg 121(1):277–281
with medialization. Plast Reconstr Surg 123(2):716–725
19. Rohrich RJ, Raniere J Jr, Ha RY (2002) The alar contour graft: cor-
8. Gruber RP, Friedman GD (2002) Suture algorithm for the broad or
rection and prevention of alar rim deformities in rhinoplasty. Plast
bulbous nasal tip. Plast Reconstr Surg 110(7):1752–1764
Reconstr Surg 109(7):2495–2505
9. Gruber RP, Grover S (1999) The anatomic tip graft for nasal aug-
20. Strauch B, Wallach SG (2003) Reconstruction with irradiated
mentation. Plast Reconstr Surg 103(6):1744–1753
homograft costal cartilage. Plast Reconstr Surg 111(7):
10. Gruber RP, Kryger G, Chang D (2008) The intercartilaginous graft
2405–2411
for actual and potential alar retraction. Plast Reconstr Surg 122:326
 Rhinoplasty in Patients
with Malformations of the Head
and Neck
Gian Vittorio Campus, Carmine Alfano,
and Federico De Gado
Syndromes of the first branchial arch include malformations
involving derivatives of the first branchial arch, with or with-
out associated malformations or embryological abnormali-
ties in which the lower face, internal ear, and oral cavity are
primarily involved, better known as mandibulofacial dysos-
tosis. Face development occurs within 3–4 weeks of intra-
uterine life. Each pathogen that affects embryos between the
third and the fourth weeks, when these structures are devel-
oping, is able to damage them and explains the coexisting
facial skeletal alterations [2]. Although the incidence of oro-
facial malformative syndrome is not easily evaluable, the
congenital deformity and genetic alterations affecting struc-
tures derived from the first branchial arch remains high.
1 Classification of Nasal Deformities
Pavy et al. [3] developed a comprehensive classification
scheme dedicated to congenital nasal anomalies, based on a
retrospective review of 261 patients with congenital nasal
anomalies [4].
2 Craniofacial Syndromes
Nasal hypoplasia is observed in many craniofacial syn-
dromes. Apert syndrome is a rare autosomal recessive disor-
der known as type I acrocephalosyndactyly. It often manifests
as bilateral narrowing of the bony nasal cavity with choanal
stenosis or atresia [5].
G.V. Campus, MD
Dipartimento di Dermatologia, Università di Sassari, Sassari, Italy
C. Alfano, MD
Dipartimento di Scienze Chirurgiche, Università di Perugia,
Perugia, Italy
F. De Gado, MD, PhD (*)
Private Practice, Rome, Italy
e-mail: degadof@hotmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_47
Fraser syndrome, a rare autosomal recessive disorder,
often manifests as cryptophthalmos (whereby the eyelids fail
to separate in each eye or there is complete or partial absence
of eyelids, microphthalmia, or anophthalmia) and nasal
anomalies including a broad nose with midline groove, a
depressed nasal bridge, hypoplastic nares with colobomas,
choanal stenosis, and a beaklike appearance; syndactyly;
genital malformations; absent or malformed lacrimal ducts;
and mental retardation [6].
Binder syndrome, or nasomaxillary hypoplasia, is
characterized by midface retrusion, hypoplasia of the
anterior nasal spine, an abnormal short nose and flat
nasal bridge, a short columella, and an obtuse nasofrontal
angle and prognathism [7]. Craniofacial microsomia or
Goldenhar syndrome (also known as oculo-auricolo-ver-
tebral spectrum) is characterized by incomplete develop-
ment of the ear, nose, soft palate, lip, and mandible,
epibulbar dermoid, ear abnormalities, and malformations
of vertebrae, and can affect the nose with varying degrees
of hypoplasia [1].
3 Proboscis Lateralis
and Supernumerary Nostrils
3.1 Etiology and Embryogenesis
Proboscis lateralis (also known as congenital tubular nose) is
an extremely rare anomaly whereby the external nose fails to
develop on one side and is replaced by a tubular structure
emanating from the medial canthus [8]. The condition is
caused by the developmental failure or absence of medial
and lateral nasal processes, resulting in the fusion of the
maxillary process with the contralateral nasal process.
Supernumerary, or accessory, nostrils are a rare type of con-
genital nasal anomaly. They can be associated with such
malformations as facial clefts and can be unilateral (most
cases) or bilateral. The accessory nostril may communicate
with the ipsilateral nasal cavity [1].
669
670 G.V. Campus et al.

3.2 Clinical Presentation and Management

Proboscis lateralis is characterized by the absence of the

nasal cavity and paranasal sinuses on one side. The nasolac-
rimal duct ends blindly. Proboscis lateralis may be associ-
ated with other congenital anomalies, particularly those of
the central nervous system. Surgical treatment involves
rerouting of the nasolacrimal duct and excision of the tubular
deformity. Reconstruction may be a staged procedure, com-
mencing during adolescence. Surgery for supernumerary or
accessory nostrils is recommended, with early excision of
the fistulous or blind tract, or a fistulorhinostomy when the
proximal portion is not accessible with a local skin flap to
cover the defect.

4 Arhinia, Polyrrhinia

4.1 Arhinia

Arhinia is the congenital absence of the external nose, nasal

cavities, and olfactory apparatus [9].

Fig. 1 An infant with arhinia

4.2 Etiology and Embryogenesis
This extremely rare entity is often associated with anomalies
of the ocular and central nervous systems. It has been associ-
ated with inversion and trisomy of chromosome [9].
distraction generates essential bone and soft tissues, which
both improves facial aesthetic proportionality and facilitate
superior reconstructive efforts.

4.3 Clinical Presentation and Management
Arhinia constitutes a rare congenital malformation of the
midface, with fewer than 25 cases previously reported.
Phenotypic expression ranges from hyporhinia, mani-
fested by the lack of external nasal structures, to total arhinia,
characterized by a failure of formation of the external nose,
nasal airways, olfactory bulbs, and olfactory nerve. Arhinia
is clearly evident at birth, with only a depression located
between the eyes (at the normal position of the external nose)
(Fig. 1). Since neonates are obligate nasal breathers, respira-
tory distress is usually noted, but not always. The maxilla is
underdeveloped, and a high arched palate is common.
Surgical repair is staged, beginning at an approximate age of
5 years. Final revision surgery is performed near puberty.
The operation creates new nasal cavities and an external nose
(by use of local flaps and autologous cartilage grafts or pros-
thetic devices). Vertical distraction osteogenesis (a surgical
technique that allows procurement of new bone by mechani-
cal lengthening of the healing bone after osteotomies) repre-
sents a modality for elongation of the midface. Midfacial
4.4 Polyrrhinia
Two completely formed noses characterize this extremely
rare anomaly. Duplication of media nasal processes during
embryogenesis is believed to cause polyrrhinia. Management
consists of excision of the medial halves of each nose [10].
5 Nasal Cleft (Cleft Lip and Palate)
This is a face deformity that alters the superior lip, alveolar
ridge, and hard and soft palate; these structures are character-
ized by a cleft of variable range resulting from unsuitable
development and melting of frontal processes and other facial
processes, leading to various degrees of deformity (facial
cleft classification by DeMyer, Sedano, and Tessier) [11]
(Fig. 2). Superior lip cleft may be bilateral or monolateral;
affecting all the structures or some of them. For instance, it
can affect just the palate or just the lip. Cheilognathopalatoschisis
is fairly frequent, affecting 1 in 500–700 newborns [12]. This
disorder can be caused by the genetic background of one of
both relatives, known as inherited forms, which affect
Rhinoplasty in Patients with Malformations of the Head and Neck 671

a b

Fig. 2 Tessier classification for soft tissue (a) and bone (b)

a b

Fig. 3 Septum deviation. (a) Nasal tripod declivity. (b) Clinical appearance

20–30 % of cases. In the remaining patients several external
factors may be responsible for the deformity, including:
• Drug consumption (antibiotics, salicylates, corticoste-
roids, estrogens)
• Infective diseases (rubella, chickenpox, toxoplasmosis,
flu or flu-like infections)
• X-ray exposure
For a cleft lip and palate to develop, however, the intensity
and duration of the causative agent and, especially, the period
of pregnancy during which it occurs (the most dangerous
period is between weeks 8 and 12 of intrauterine life) are of
utmost importance.
Cleft nasal deformity is a complex anomaly, and proper
correction requires considerable surgical talent and experi-
ence. Surgeons must continue to tailor approaches to indi-
viduals and evolve techniques to best serve each patient.
Children who benefit from good surgical repair have a chance
to mature with fewer psychological sequelae from this defor-
mity. The nasal deformity is strictly related to the labial
deformity and maxillary hypoplasia (cheilognathopalatos-
chisis or labiopalatal cleft, commonly called “hare lip”) [13].
Its correction must integrate with that of the lip and the
alveolo-maxillary cleft that supports the nasal wing. The sur-
geon must aim to establish a functional nasal airway in addi-
tion to improving cosmesis. In normal anatomical conditions,
the nasal septum and the nasal wings create a tripod that lies
on symmetrical bone bases. In the cleft patient, the maxillary
bone is hypoplastic and the tripod reclines on the pathologi-
cal side, inducing a collapse and a widening of the nasal
base; the septum is deviated toward the healthy nostril
(Fig. 3a, b). Maxillary hypoplasia is often underestimated; it
must be corrected before or during the rhinoplasty with graft
apposition (onlay graft) or by orthognathic surgery com-
bined with orthodontia before and after surgery.
5.1 Evaluation
The preoperative photograph represents the starting point for
the preoperative evaluation. Apart from professional skills,
672
Table 1 Congenital nasal deformities classification
Type I: Hypoplasia and atrophy (paucity, atrophy, or
underdevelopment of skin, subcutaneous tissue, muscle, cartilage,
and/or bone)
Type II: Hyperplasia and duplications (anomalies of excess tissue,
ranging from duplications of parts to multiples)
Type III: Clefts (the comprehensive and widely used Tessier
classification of craniofacial clefts is applied)
Type IV: Neoplasms and vascular anomalies (both benign and
malignant neoplasms are found in this category)
surgeons must have a great aesthetic sensitivity, and above
all must listen to the patient and understand the requests
directing them in the best way; the patient must understand
the surgeon’s plan and the underlying complexity of the
nasal correction, above all because it might need several sur-
gical interventions at intervals. The most frequent deformi-
ties, summarized in Table 1, may be isolated or combined.
For secondary nasal deformity in the mono- or bilateral cleft,
see also Table 1.
5.2 Treatment
A complete treatment cannot neglect the development of the
whole maxillofacial region. No perfect surgical technique
exists, so the approach needs to be orthopedic-orthodontic.
Surgeons must tailor approaches to individuals and evolve
techniques to best serve each patient. This can be obtained
by combining the surgical phases with an early orthopedic
treatment, so that the facial development is modified, if dis-
advantageous, through the use of “plaques.” An early correc-
tion is desirable at the same time as the primary lip correction;
this approach is suggested by several authors such as
McComb and Mulliken; long-term results shows, in fact, that
an early correction of rostral cartilage does not interfere with
development. Early surgical treatment avoids, therefore, the
establishment of unhealthy habits related to the oral sphere,
concerning suction, swallowing, and breathing, which can
worsen even more the orthodontic disease type and, there-
fore, phonetics [14]. A second approach is described by
Millard in his technique of rotation-advancement, consisting
in rebuilding the nostril floor, giving back symmetry to the
base wings and raising the columella without molding the
wing cartilage. A third, more objectionable, approach con-
sists in neglecting the nasal correction at the moment of the
primary lip closure, since it causes deformity difficult to tol-
erate by the child; this correction often needs a complete
revision of the labionasal cleft. The secondary correction of
a nasal deformity can be achieved at any age, but the major-
ity of authors suggest doing it at 8 years old with alveolar
bone graft, for the following reasons: a correct joint of the
dental arcade can be achieved with orthodontia; the maxillary
G.V. Campus et al.
hypoplasia, associated to the nasal deformity, can be cor-
rected by a bone graft placed at location of the alveolar cleft
closure; the placement of the graft (onlay) in the canine pit
should, therefore, improve the projection of the nasal wing.
The secondary rhinoplasty, in the cleft sequelae, must correct
the shape and the function. The aesthetic and functional sur-
geries are often realized at the same time.
6 Surgical Therapy
6.1 Monolateral Cleft
6.1.1 Restoration of Alar Base Symmetry
Although the reconstruction of the nostril floor, combined
with a reorientation of the nostril muscles, is essential, the
main intervention necessary for restoration of the wing
symmetry is correction of the hypoplasia of the maxillary
pillar, which must be achieved before or during the rhino-
plasty [15].
6.1.2 Some Technical Details Applicable
to the Nasal Deformity
Bone Apposition (“Onlay” Grafting)
The piriform aperture is reached through a vestibular
approach, taking advantage of the introduction of the alveo-
lar bone graft; the periosteum is then extensively undermined
until the infraorbital nerve is visualized. Great care is taken
to avoid damaging the soft tissues.
To achieve a suitable lift of the nostril wings, usually
autologous corticocancellous iliac or parietal bone grafts are
placed, through the piriform aperture; a slight hypercorrec-
tion is suggested, since a certain amount of graft reabsorp-
tion is expected. The vestibular suture must necessarily be
waterproof [12].
6.1.3 Maxillary Osteotomy
The maxillary hypoplasia can be corrected by a Le Fort I
osteotomy of the small segment.
6.1.4 Correction of Nasal Projection
The projection of the nasal tip must be evaluated with regard
to not only the dorsal nose but also the overall face propor-
tions. Projection can be normal, extreme, or poor, weakening
the anatomical pillar structures.
6.1.5 Anatomy
The main anatomical characteristics of the nasal tip are: the
nasal tip skin; the stiffness of the wing cartilage of the lateral
and medial crus; the length and stiffness of the medial crus;
and the bonding of medial crus to the caudal septum margin.
In the cleft sequelae, the nasal tip is flat, deflected, and
Rhinoplasty in Patients with Malformations of the Head and Neck
Fig. 4 Nasal deformity in the unilateral cleft
asymmetric. There certainly is a lack of projection, but the
deformity is primary linked to an alar cartilage asymmetry;
the medial crura are too short and deviated (Fig. 4). The
improvement in nasal projection is almost always related to
a correction of wing cartilage asymmetry.
6.1.6 Entry Through the Nasal Tip
It is possible to access to the nasal tip by the endonasal (mar-
ginal, intracartilage, or intercartilage) or open route (trans-
columellar) (Fig. 5).
6.1.7 Intranasal Route
A rhinoplasty of the nasal tip via intranasal access is inadvis-
able in the presence of cleft sequelae, since it leads to incom-
plete correction; the open transcolumellar route is mush
preferred. Any aberration of the nasal tip structure, even the
slightest, can be easily identified and moreover allow the
construction of a normal anatomy by rehanging, molding, or
increasing the cartilage using cartilage grafting.
6.1.8 Incisions and Open Approach
Scarring sequelae must not be aggravated; therefore, if a scar
crosses the columella, it is removed and is used as a surgical
approach, otherwise a median transcolumellar “V” incision
673
or “scale” type is used. Wing cartilage is then dissected
according to the classical technique of open rhinoplasty.
6.1.9 Technique for Augmentation of Nasal
Tip Projection
In a healthy adult, the nasal projection is based on
the equilibrium between the cartilage structures and the
integuments, in which elasticity plays a key role. In the cleft
patient, the lack of covering tissue elasticity is the main
limitation to improvement. As already pointed out, the
lift of the nasal wings in maxillary hypoplasia correction
is a more effective action for releasing the nasal wings
and tip.
6.1.10 Molding of the Alar Cartilage
In the cleft patient, the corner between the lateral and medial
crura is obtuse, and therefore can be cramped. A similar
action can be performed on the contralateral wings. In this
way an open and straight arch is turned into a taller and
sharper arch. This technique is not truly satisfactory since it
reduces the sharpness of the nasal tip; therefore, cartilage
stiffness is insufficient to balance the skin power. In the
cleft’s sequelae, the correct projection of the nasal tip can be
achieved with a columellar strut.
674
Fig. 5 Approaches to the nasal tip. Marginal approach (a); intracarti-
laginous appoach (b); intercartilaginous approach (c); transcolumellar
approach (d)
Fig. 6 Septal grafting
6.1.11 Columellar Strut
The aim is to strengthen the sagittal pillar of the basal tip.
In the healthy nose, the medial crura have the role of pro-
tecting the nasal tip as an awning. In the cleft patient, the
medial crus is too short and deviated, and needs to be cor-
rected. The columellar strut can be either a cartilage graft,
harvested from the nasal septum (the open transcolumellar
approach in fact offers an easy access to the cartilage and
bone septum, from which fragments can be taken (Fig. 6))
or from conchal bowl cartilage (Fig. 7) (ideal for molding
G.V. Campus et al.
Fig. 7 Bowl grafting
Fig. 8 Columellar strut
the nasal tip, but elastic and friable and of low utility as a
strut); or a bone graft: cartilage and bone of nasal hump,
bone of little hump (although nasal back reduction can be
used to achieve a better nasal projection; better than carti-
lage regarding tegument pressure) or a parietal bone graft
(ideal transplant for nasal cleft). Although the septal carti-
lage is more accessible, it is better to graft a bone strut
made stable on the nasal spine with osteosynthesis, inserted
between the medial crura (Fig. 8). The aim of the second-
ary rhinoplasty is not just to improve the projection but
also the nasal shape, and for this reason can be added to
the septal or bowl strut. Placed at the columellar summit, a
Sheen triangular graft increases the projection and
improves the lobular shape (Fig. 9). Onlay grafting
improves the nasal projection (Fig. 10). Grafting needs to
be completely stabilized, and in fact does not support the
smallest defects.
Rhinoplasty in Patients with Malformations of the Head and Neck
6.1.12 Molding of the Nasal Wing
After transcolumellar access, it is possible to observe three
situations:
• The cleft side cartilage has a normal size and position but
is disfigured
• The cartilage has a normal size but is malpositioned and
is disfigured
• The wing cartilage is atrophic and in the wrong position
The answer to the first situation is structural rhinoplasty
of the tip according to Tebbetts. If the cartilage size and posi-
tion are normal, there is no need to resect or immobilize. The
defect is corrected by modifying the cartilage structure with
sutures; the molding can be simplified by slightly scarifying
the cartilage.
Fig. 9 Sheen grafting
Fig. 10 Onlay grafting added to the columellar strut
675
Despite the cartilage anatomy being restored, the nasal
wings can preserve a tendency to collapse; such a problem
can be corrected by anchoring the reshaped cartilage to the
contralateral wing cartilage, the septum, or the triangular
cartilage (Fig. 11).
The second situation solution is less obvious.
Given the high cartilage fragility, its dissection and mobi-
lization are delicate procedures. It is better to choose, from
the beginning, molding of the nasal wing with a cartilage
septal or bowl onlay graft (Fig. 12). The wing cartilage is in
this way reinforced and stabilized on the contralateral wing
cartilage, the septum, and/or triangular cartilage. The only
solution to the third situation is the use of an onlay graft.
Fig. 11 Structural rhinoplasty by Tebbetts
Fig. 12 Wing cartilage molding with onlay grafts
676
6.1.13 Tegumental (Soft Tissue) “Defect”
Correction
At the moment of closure of the open rhinoplasty, after the
improvement of the nasal tip projection and shape, one often
has to deal with the problem of tegumental tension.
To solve this tension several techniques have been
proposed:
• Correction of the columella wing by Z-plasty (Fig. 13);
this can be combined with cartilage grafting to improve
the lobular shape
• Gradual release of the lateral vestibule of the nostril by
Z-plasty or a V-Y flap with mucosal graft (Fig. 14)
• Inverted U incision and a Z-plasty in the lateral vestibule
and wing cartilage reassessment
6.2 Bilateral Cleft
The surgical techniques mentioned hitherto focus on unilat-
eral cleft lip deformities but also apply to bilateral deformi-
ties [16]. Evolution of surgical techniques for the treatment
of bilateral cleft lip deformities has lagged behind treatment
for unilateral deformities. This may reflect the relatively
lower prevalence of bilateral cleft lip deformities.
Computerized constructions reveal that bilateral cleft lip
Fig. 13 Correction of columella wing
Fig. 14 Lateral vestibule release by Z-plasty or a V-Y flap
G.V. Campus et al.
nose may be viewed as a duplicated image of unilateral cleft
lip nose. Stigmata include a broad, flat, bifid tip, wide alar
bases, and short columella, all of which contribute to the
overall porcine nose appearance. The nasal dorsum may
exhibit lack of height, but is usually within normal limits.
The hallmark of bilateral cleft lip nose is a short columella.
The columella could be lengthened by mobilizing the skin
filter or the nostril flap; Millard popularized what is perhaps
the best known columellar lengthening technique. Millard
advocated the use of forked flaps, one from each side of the
prolabium, which are banked within the nasal sills during
primary lip repair until secondary rhinoplasty is performed.
These flaps are then retrieved and rotated into the columella
of the child when aged 2–4 years to achieve columellar
lengthening. However, McComb reviewed his cases of pri-
mary columellar repair using forked flaps and discovered
that by adolescence, three unfavorable features developed:
1. The columella overlengthens
2. The nasal tip broadens
3. Downward drift of the lip: columellar conjunction occurs
in conjunction with an unsightly transverse scar
Therefore, the Millard forked technique lengthens the col-
umella but reduces the nostril flap, worsening the scar results
(Fig. 15). McComb discourages borrowing tissue from the
Rhinoplasty in Patients with Malformations of the Head and Neck
prolabium and favors using only nasal tissue to reconstruct
the columella. He argues that surgical repair should focus on
re-establishing normal alar shape, which in turn naturally
elongates the columella. McComb achieves this result by
suturing the medial crura of the alar cartilages together, which
lengthens the columella and corrects the broadened nasal tip.
Mulliken states that the already flattened nasal ala contin-
ues to separate over time as a result of muscle tension.
Therefore, Mulliken favors primary alar correction, as does
McComb, to achieve columellar length and proper shape of
the nasal tip (Fig. 16).
7 Secondary Functional Rhinoplasty
Most children with lip/nasal sequelae have never breathed
normally. Relatives are used to seeing their child breathing
with the mouth, snoring, or with an ongoing congested nose.
This kind of breathing is caused especially from nasal defor-
mities such as septal deviation, hypertrophic inferior turbi-
nate, internal and external valve anomalies. The defect can
Fig. 15 Forked technique by Millard
Fig. 16 Cronin technique
677
be increased from a secondary rhinoplasty made without
paying attention to nostril function or after an incomplete
velopharyngeal correction. Poor nasal breathing can lead to
apnea, disturbed sleep, hypersomnia, generalized fatigue,
and poor scholastic performance [17]. The surgeon must aim
to establish a functional nasal airway in addition to improving
cosmesis. Adult studies have corroborated that postsurgi-
cally corrected noses maintain significantly smaller airways
than noncleft noses. Hence, parallel goals of cosmetic and
functional improvement must be aimed for.
8 Deformity
Deformity and position of osteomuscular structure depend
on the prolonged action of mechanical factors that in the
fetal period “deform” an already completed structure during
the intrauterine organogenesis.
The nasal deformity is strictly linked to the lip deformity and
to the maxillary hypoplasia. The external valve can be deformed
by tight narinal opening, external nostril vestibular tightness,
678
Fig. 17 Septal deformity types
dislocation of the lateral crus of the alar cartilage, deviation of
the septal caudal portion, or a too wide columellar base.
There are four septal deformities (Fig. 17):
• The most common type (60 % of cases) is type I, which
consists of a declivity of the anterior nasal thorn in the
healthy nostril and a flexing of the superior part of the
septal cartilage of the nostril from the cleft side, causing
shrinkage of the internal valve and the septal inferior side.
• In types I, II, and III, the bone septum deviates in the nos-
tril of the cleft side.
• Type IV is observed in the bilateral cleft, and consists of
complete flexing of the cartilage and bone septum in one
or other nostril. An inferior turbinate hypertrophy is
observed in the majority of the patients in the side where
a major volume exists between the septum and the lateral
nasal wall, to the nasal floor height. Furthermore, an off-
set turbinate hypertrophy is observed in the nostril of the
cleft side in deviation types I and II.
The following alterations can be observed:
• Inclination of the superior septal part from the cleft side
that reduces the valve corner
• Surgical scar or nasal synechia
• Abnormal flaccidity or excessive resection of the triangu-
lar cartilage
• Endonasal luxation of the posterior edge of the wing
cartilage
• Hypertrophy of anterior inferior turbinate
• From the healthy side, inclination of the nasal spine and
of the septal inferior edge in types I and II or the cartilage
septum in type III.
9 Correction of the External Valve
During the primary healing more attention must be paid to
the nasal deformity correction to restore the respiratory func-
tion. Valve deformity correction techniques are similar to
those described to correct nostril soft tissue deficit.
G.V. Campus et al.
9.1 Narinal Opening
The narinal opening width can be regulated, adapting the
muscular cingulum of the nostrils to the contralateral mus-
cles on the medial line, during the complete lip and nasal
reconstruction. In some cases, the narinal opening cannot be
widened because of excessive skin resection during the
primary correction. The stenosis is removed with a transposi-
tion flap or a mucosal island flap.
9.2 External Nasal Vestibule
This can be retracted from deep adherence by removal while
undermining the external edge of the cleft; the nares are cor-
rected according to earlier described techniques.
9.3 Alar Cartilage Dislocation
It is possible to access the cartilage with an endonasal inci-
sion along the anterior edge of the lateral crus, which unfas-
tens the superficial face and releases the tail. The cartilage
released in this way is replaced and anchored to the alar con-
tralateral cartilage (Fig. 18). Although elegant, the endonasal
access offers minor margin within which to maneuver com-
pared with open rhinoplasty.
10 Columellar Correction
The columella is viewed as foreshortened in cleft lip nasal
deformity. Two views regarding the best surgical method
exist. Some surgeons argue that the columella requires pri-
mary correction while others maintain that reshaping the
nasal ala is sufficient to affect columellar length. Proponents
of reshaping believe that the columella owes its retracted
appearance to the horizontal position of the nasal ala [18].
Therefore, reseating the nasal ala in an anterior-posterior
oval is thought to naturally elongate the columella. The Ivy
modification of the Blair procedure entails medially and
anteriorly rotating a laterally based nostril rim flap to
Rhinoplasty in Patients with Malformations of the Head and Neck 679

Fig. 18 Correction of dislocated wing cartilage

Fig. 19 Ivy modification of the Blair procedure. Laterally based nostril rim flap rotated medially inward

Fig. 20 Dingman technique. Nostril rotated via columellar and alar-based flap

lengthen the columella by repositioning the nasal ala.
Similarly, the Dingman technique requires medially rotat-
ing a columellar and alar-based flap (Fig. 19). Many tech-
niques are available for primary correction of the columella.
The simple V-Y advancement flap may serve to lengthen
the columella if adequate columellar width and upper lip
tissue are present (Fig. 20). Similar to the V-Y flap, an ante-
riorly pedicled rectangular flap may be elevated to provide
greater length (Fig. 21). The Brauer-Foerster technique
uses fan-shaped flaps along the medial and anterior margin
of the alar rim, which can be pulled medially to increase
columellar projection (Fig. 22). The Cronin procedure
involves simultaneous anterior bilobed flap advancement
and posterior midline columellar flap advancement
(Fig. 23). Techniques that lengthen the columella may be
more effective for patients with bilateral cleft lip for whom
symmetric columella advancement is desired. More radical
reconstruction is required when the columella is completely
absent [19]. The upper lip is the ideal donor site for recon-
struction. However, the upper lip is often scarred or defi-
cient secondary to cleft lip. Lower lip tissue may be
transferred to the columella, or nasolabial flaps may be
680 G.V. Campus et al.

Fig. 21 Rectangular flap for columellar lengthening

Fig. 22 Brauer-Foerster procedure for columellar lengthening via medial rotation of bilobed flaps

Fig. 23 Cronin procedure for columellar lengthening. Anteriorly based bilobed flap is advanced anteriorly, and posteriorly based columellar flap
is advanced posteriorly

recruited. A full-thickness skin graft (FTSG) may be buried
below upper lip skin for use in reconstructing the
columella.
11 Septal Deformity Correction
Surgical correction aims at establishing a patent nasal airway
while creating a more favorable external nasal appearance [20].
Timing of septal surgery is controversial. One view is that early
septal surgery disrupts natural septum growth, resulting in
stunted nasal growth. Another view is that delay of septal sur-
gery may cause unfavorable maxillary growth, especially if the
child is a significant mouth breather [21]. Clearly, conservative
septal surgery, including reconfiguring septum shape by scor-
ing portions of it, may be a compromise and may provide a
meaningful solution. Considering the benefit of turbinate
reduction or out-fracturing to increase nasal airflow, one needs
to exercise caution when performing surgery on abnormal anat-
omy, as vascularity and integrity of the structures may be less
Rhinoplasty in Patients with Malformations of the Head and Neck
than optimal [22]. Septoplasty takes place under general anes-
thesia [23]. The septal mucoperichondrium, the nares floor, and
the soft tissue around the nasal crest are infiltrated with xilo-
caine 1 % plus epinephrine (1/200,000). The operation starts
10 min after the infiltration that has already permitted hydraulic
dissection of the mucoperichondrium. It is possible to access to
the septum by four ways (Fig. 24):
Fig. 24 Accessing the septum. 1 inter-septal-columellar incision.
2 oblique incision. 3 intra oral access. 4 trans columellar access
Fig. 25 Double undermining
of the mucoperichondrium
681
1. An interseptal-columellar incision (Cottle incision)
2. An oblique incision to 10–15 mm from the inferior septal
edge (Killian access); this offers restricted access
3. Endoral access, indicated only to facilitate the septal base
resection
4. External transcolumellar access, which gives ideal access
to the septum
Whatever the access, it is essential to undermine the
mucoperichondrium by two methods (Fig. 25):
• An anterior approach (and superior in the external
approach) that extends behind to the bone septum.
• An inferior approach, created by undermining the
mucoperichondrium of the nasal crest and premaxil-
lary crest; this dissection is delicate and can be made
more difficult by an anterior alveolar bone graft. It is
necessary, therefore, to reunite loose matter; this oper-
ation must be done with a cold-blade lance under
direction vision, since there is a high risk of creating a
breach in the mucoperichondrium. A septal face, a
nasal thorn, and one of the ridges of the premaxilla are
in this way completely released. It is performed on the
posterior part of the cartilage septum. Later it is
released from the nasal spine, the premaxillary ridge,
and the plowshare. Unglued and released the septum,
the blocked elements the nares can be corrected: the
plowshare and the perpendicular plate are resected
under direct vision.
• The septum is straightened with vertical or horizontal
sutures according to the degree of flexing.
682
Fig. 26 Enlargement of the valve corner through septal grafts
• The caudal edge is moved toward the midline and stabi-
lized with the nasal spine, or in a pocket in the columella.
The mucoperichondrium is reglued to the septum with
some pierced stitches; the nares are plugged for 24 h. The
described technique permits correction of the majority of
septal deformities; however, some deviations are severe
enough to justify a submucosal resection or that the sep-
tum should be completely resected, with molding
replaced.
11.1 Inferior Turbinates
The turbinate reduction technique varies for each patient
according to the degree and obstruction site. Patients that
show turbinate hypertrophy covered by healthy mucosal can
benefit from a turbinoplasty associated or not with septo-
plasty. If a patient shows a turbinate hypertrophy, covered
from pathological mucosa, the anterior part of the turbinate
and a portion of pathological mucosa are resected (turbinec-
tomy) [24].
G.V. Campus et al.
11.2 Internal Valve Region
In general, the correction of septal deformities of the inferior
turbinate and the lateral vestibule clearly improves the inter-
nal valve function, although it can still be disturbed by a
triangular cartilage collapse. The valve corner is faced from
outside and opened with the interposition of septal cartilage
grafts (spreader grafts) between the triangular cartilage and
the septal superior edge [25] (Fig. 26).
12 Outcome and Prognosis
Cleft lip nasal deformity is a complex anomaly, and proper
correction requires considerable surgical talent and experi-
ence. Surgeons must continue to tailor approaches to individu-
als and evolve techniques to best serve each patient. Children
who benefit from good surgical repair have a chance to mature
with fewer psychological sequelae from this deformity.
Clinical Cases (Figs. 27 and 28)
Rhinoplasty in Patients with Malformations of the Head and Neck 683

a b c

d e f

Fig. 27 (a–c) A 16-year-old patient with lip cleft sequelae, distortion, of pyramid deformity and the nasal tip by using grafts taken from the
and left nasal ala flattening, and shortness of the septal-columellar seg- auricular bowl (postoperative view)
ment (preoperative view). (d–f) Open rhinoseptoplasty with correction
684
a b
d e
g h
Fig. 28 (a–c) A 15-year-old patient with cleft lip and palate. There is
distortion and the absence of the nasal tip anatomical subunit. (d–f) Open
rhinoseptoplasty, intraoperative view: cicatricial unbridling and isolation
of the residual structures of the nasal tip anatomical subunits, preparation
and placement of a “strut” type graft and “L” molding graft, taken from
G.V. Campus et al.
c
f
i
the costal cartilage (VIII rib) to rebuild the “dome” and the septocolumel-
lar segment; grafting taken from auricular bowl and shaped to rebuild the
missing and malformed segments of the alar cartilage. (g–i) Postoperative
images; extension of the septocolumellar segment and the reconstruction
of the different anatomical subunits of the inferior nasal third
Rhinoplasty in Patients with Malformations of the Head and Neck 685

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 The Twisted Nose
Wolfgang Gubisch and J. Eichhorn-Sens
The twisted nose is the most common deformity in noses, in
our practice up to 50 %, but it presents a challenge to rhino-
plastic surgeons as functional problems as well as aesthetic
deformities often occur. The terminology used – deviated,
twisted, crooked, asymmetric, scoliotic, and deflected – is
confusing.
Not all of twisted noses are very obvious and remarkable,
and very often there is also an asymmetry of the facial skel-
eton. This of course influences also the axis of the nose.
Therefore, it is necessary to do a very precise analysis in
order to discuss the chances of surgical correction. The goal
is to straighten the nose and not just to improve a severe
deviation.
There is no question that the correction of a twisted nose
has the highest failure rate and the reason offered for that
often is not the surgeon but the so-called memory of the car-
tilage. We believe that the main cause of redeviation of the
nose is a residual septal deviation, and then as the septum
goes, so goes the nose [1].
The twisted nose is the example “par excellence” that
every surgeon who undertakes a rhinoplasty must be able to
correct the septum as well as the external nose simultane-
ously. This dictum is more important for the badly deformed
septum, which is of course even more difficult to handle than
just a subluxation out of the anterior border of the septum.
From our point of view, this is a topic where cooperation
between ENT surgeons and plastic surgeons comes to its
limits, where the ENT surgeon corrects the septum and the
plastic surgeon shapes the nose. The reason for this is that
the aesthetic and functional goals are so interconnected that
only one has to take the responsibility for the outcome, which
means the surgeon who undertakes the correction of a twisted
nose has to correct the septum as well as the external frame-
work and this is true for both kinds of surgeons.
J. Eichhorn-Sens, MD • W. Gubisch, MD (*)
Department of Facial Plastic Surgery,
Marienhospital Stuttgart, Stuttgart, Germany
e-mail: wolfganggubisch@vinzez.de; info@dr-eichorn-sen.de
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_48
1 History
Hieroglyphics in Egyptian tombs as far back as 3,000 BC
suggested surgical maneuvers to correct deviated noses
[2, 3].
In 1845, Dieffenbach divided the upper lateral cartilages
from the septum and corrected the position of the nose with
bandages [4]. In 1889, Trendelenburg performed endonasal
lateral osteotomies, percutaneous superior osteotomies, and
division of the septum along the nasal crest [2, 5]. Joseph
described a lateral osteotomy at the “small” side and a trian-
gular wedge resection of bone was removed from the “broad”
side, to correct the bony twisted nose [6]. More recently,
Fomon described a similar technique in 1936 in which a
wedge of bone was removed from the broad side together
with asymmetric reduction of the nasal hump [7]. For the
correction of the deviated septal cartilage Joseph used exter-
nal traction [6].
2 Etiology of Deviation
The twisted nose may have different origins. One reason
may be the compression of the facial skeleton during deliv-
ery when passing the head through the birth canal causing
subluxation of the cartilage out of the vomerine groove. An
immediate reposition with a Q-tip could solve the problem
but at least in our area such a routine examination during a
newborn screen is not performed.
Kent et al [8] is in agreement the findings of Jeppsen and
Windfield, Jazbi, and Alpini et al [9–11] of the incidence of
neonatal septal deformities being less than 4 %. Jazbi [10]
and Gray [12] support the idea that the septal deviation
occurs as the newborn head undergoes internal rotation in the
pelvis. This theory has been cited to explain a relationship
between the presentation of the head and the side to which
the deviation occurs. The results from Kent et al. [8] show an
equal incidence to each side, and no correlation with the pre-
sentation of the head. Gray et al. [13] suggested an incidence
687
688
of neonatal septal deformity between 48 and 60 %. They
stated that a neonatal septal deformity will never straighten
spontaneously [14]. They argued that most deviations
become worse with subsequent growth of the nose and later
development may lead to a crooked nose. Kent et al. [8]
found out in a review of 1,000 consecutive neonates that neo-
natal septal deviations are relatively uncommon. They rarely
cause symptoms and spontaneous correction does occur in a
significant proportion with growth.
The most commonly seen deviated noses in adults results
due to a lateral blow with an infracture of the ipsilateral nasal
bone and outfracture on the contralateral side. This type of
injury is almost always associated with a shift of the nasal
septum [15]. Frontal impact injuries are typically higher
energy injuries that result in a greater degree of comminution
and septal injury and may also result in crush injury to the
nasal bone and septum [15].
Most existing deformities have in the history some minor
nasal traumas, which the patient had already forgotten.
Intrinsic and extrinsic forces result in septal distortion and
deviation responsible for the functional and aesthetical
deformity. The extrinsic forces are secondary to scar con-
tractures or congenital asymmetric attachments of the osseo-
cartilaginous skeleton, including attachments between the
bony pyramid, the upper and lower lateral cartilages, and the
septum. The intrinsic forces are either those acquired or
inherent septal cartilaginous abnormalities [16].
It is also possible, that the nasal deformity is secondary to
a previous nasal surgery.
3 Acute Twisted Nose
In the acute fracture situation, repositioning of the fractured
nasal bones should be performed – but keep in mind that in
children these are mostly greenstick fractures so a procedure
may be not necessary in these cases.
If the cartilage is fractured this may be detected during
examination – even it can be camouflaged by a septal hema-
toma – but this must be evacuated. Very often, the cartilage
is not fractured but only partially ruptured. This, over time,
results in a bowing with consecutive deformity of the carti-
laginous nose. “Interlocked stresses” means the forces
locked within the matrix of the cartilage exist in a state of
balance, the outer layers being in a state of tension, the inner
layers being largely maintained in a state of compression
[17]. Verwoerd et al. [18] hypothesized that a high amount of
water (70 %), bound by hydrophilic proteins in cells and
matrix of cartilage, is responsible for stress interlocked by a
three-dimensional network of collagen fibers, present in the
cartilage and stretching out between the dense fibrous zone
under the perichondrium. Verwoerd-Verhoef et al. [19] pos-
tulated that this network is interrupted by any injury. If a
W. Gubisch and J. Eichhorn-Sens
buckling stress is applied to the cartilaginous septum that is
insufficient to cause a complete fracture through the carti-
lage, abnormal curvatures will be produced. The concave
side of the cartilage will be in compression, the convex side
in tension. Such incomplete fractures heal by overgrowth of
fibrous tissue, originating from the outer layer of the peri-
chondrium and preventing a cartilaginous reintegration of
the separated parts [20]. The overlapping edges of septal car-
tilage after trauma and the fibrous connection, during further
growth, contribute to the development of deviations and
angulations of the septum [21].
Fry [17] has showed that the distortion of the nasal septal
cartilage is thus retained and may worsen with the passage
of time. Therefore, many times it can be diagnosed only
retrospectively and not during the first examination. In the
case of falls during childhood, the region of the premaxilla
and the anterior septum is often traumatized, so that many
of the later encountered horizontal and vertical displace-
ments of the septum are developmental problems after the
trauma.
Meyer [22] recommended surgical correction once the
edema has disappeared, 8–10 days after the trauma under
general anesthesia.
If a fracture of the cartilage is found in adults, an immedi-
ate bloody revision with exact repositioning of the fragments
and stabilization by multiple tilting sutures in combination
with splinting of the septum may be the best.
3.1 Rhinosurgery in Children
Clinical evidence of the effects of nasal surgery in children,
especially of the nasal septum, is still fragmentary. A valid
argument against operations of the septum in children was
the hypothesis that the septal cartilage is an essential pillar
for the primary growth of the midface. In the literature is
found different studies with different conclusions. Verwoerd
and Verwoerd-Verhoef [21] found a three-dimensional orga-
nization of the cartilaginous septum in children with thinner
and thicker areas with growth in the sphenodorsal zone of
thick cartilage appearing to be the primarily responsible for
the normal increase in length and height of nasal dorsum and
growth in the sagittal direction of the thickened basal rim
appearing to be the driving force in forward outgrowth of the
(pre)maxillary region. They found that the interruption of
both the sphenodorsal and sphenospinal zones prevent extra
growth of the facial skeleton resulting in the nasal features
remaining the same.
Pirsig [23] confirmed the opinion of Moss [24], that
nasal septum, maxilla and premaxilla independently
develop. Kastenbauer [25] postulated, that an operation at
the transition from the cartilaginous septum to the lamina
perpendicularis has no detriment to the growth of the mid-
The Twisted Nose
face. He recommends that the vomer should not be resected
before age 12 [25].
The careful separation of mucoperichondrium in septal sur-
gery of the child has no negative effects on further growth. In
principle, partly transverse fixed fragments of the nasal septum
can be gently corrected even in childhood (from 4 years of
age) in order to ensure unimpeded nasal breathing [25].
Detailed guidelines for correction of the growing nasal septum
are described by Verwoerd and Verwoerd-Verhoef [21].
Fractures of the bony nasal pyramid do not occur so frequently
in children because the nasal bones are less prominent, and the
greater part of the nasal skeleton is cartilaginous [21]. However,
classic osteotomies in the area of the nasal pyramid do not
destroy the bony structures of the face for growth necessary.
Worldwide the relapse rate after a septoplasty in chil-
dren is approximately 20 %. This may increase to 30 % if
septoplasty is done before the age of puberty. Pirsing’s rec-
ommendation is to wait until two years after puberty if pos-
sible [23].
In our clinic, the following approach has proven helpful:
for operations in young men we operate about 1 year after
breaking voice, and in young women we operate approxi-
mately 1 year after the onset of menstruation.
4 Settled Twisted Nose
Our daily problem is not the acute twisted nose but the case
where the trauma happened a long time ago. To get an idea
what to do in these cases we have to perform a detailed anal-
ysis of the external and the internal deformities. Very often
the trauma leads not only to a deviated nose but also to a
widening of the nasal bridge.
5 Analysis
The importance of a strong emphasis on nasal anatomy and
careful clinical analysis cannot be overstated, and it is the
key to an effective and successful reconstruction.
Important factors of the history include age, history of
nasal trauma, impairment of the nasal airway, allergies, and
previous nasal surgery. The twisted nose affects all parts of
the nose, the septum, the bony vault, and the cartilaginous
framework, but it might also affect the tip, the nasal colu-
mella angle, and the base of the nose.
5.1 Age
Before an aesthetic rhinoplasty in adolescents can be carried
out, emotional maturity and the completed pubertal growth
of the nasal skeleton have to be evaluated.
689
5.2 Facial Asymmetry
Minor facial asymmetry often goes unnoticed by the patient.
These facial variations should be pointed out to the patients
preoperatively. The patients should be made to understand
the limitations these asymmetries pose in surgery of the
twisted nose [26].
5.3 Photographic Documentation
Frontal, basal, and lateral views are recorded. An additional
view that proves to be helpful in assessing the twisted nose is
the frontovertex view, with the nasion proximal and the tip
distal taken from the top of the head [27].
5.4 Frontal View
5.4.1 Midline of the Face
To determine the midline of the face, draw a line from the
interpupillary middle at the nasion to the middle of the colu-
mella to the tip of the chin. This way we can find out if the
facial skeleton is symmetric and whether there is a chance to
get an exact straight nose.
5.4.2 Eyebrow-Tip-Line
The eyebrow-tip-line is a useful landmark. The line begins at the
medial eyebrow, runs in a curve inferiorly at the border of the
dorsum and goes beyond it in the tip-defining point. The lines
should be symmetrical at both sites and should not be broken.
There are classical basic types of deviated noses: the
straight septal tilt off the vomer, the C-shaped and reverse
C-shaped deformities (usually without bony pyramid devia-
tion), and the S-shaped deformity involving a deviated bony
pyramid [16]. The nose can be also straight itself but not
perpendicular to the midline of the face [5].
5.4.3 Basal View
Deviated noses may lead to deformities, specifically asym-
metries of the lower nasal entrance. The basal view can eval-
uate the configuration of the nasal entrance, the shape of the
columella, shape of the base of the columella, symmetry of
the nostrils, position of the anterior septum (subluxation),
position of the nasal tip, and configuration of the nasal tip.
Nostril asymmetry is commonly present because of soft-
tissue growth disturbances.
5.4.4 Lateral View
Deviated noses are often combined with other deformities
that mostly depend on trauma, so in this view also an over-
projected dorsum (hump), saddling of the dorsum or a
retracted columella can be analyzed. In a twisted nose there
690
is always a different shape from both sides, so we do the
lateral view also from the right and from the left side.
6 Palpation
Examination of the nose also includes palpation to evaluate
the position of the nasal bones and cartilages, irregularities,
and the soft tissue envelope.
7 Internal Examination
An important point for the planning is to find out if the septal
frame is straight. During the internal examination septal
deviations and the dimensions of the turbinates are evalu-
ated. (Nasoendoscopy may be helpful).
8 Classification of Septal Deviation
We follow the classification of Daniel [28] based on the clas-
sifications of Lawsen and Reino [29], Tardy [30], and Jugo
[31]. Daniel [28] divides nose deformities into the following
five grades:
• Grade I – inferior cartilaginous subluxations from the
vomerine groove with deflection resulting in a spur
• Grade II – either midseptal bowing or angled deflections
due to fracture lines in either a horizontal or vertical
direction with resulting unilateral nasal obstruction
• Grade III – linear deviation due to subluxation of the
quadrangular cartilage from the vomerine groove and the
caudal septum from the anterior nasal spine, with or with-
out bowing of the septal body
• Grade IV – combination of multiple angled deformities
and subluxation of the septal body usually with deviation
of the caudal septum and occasionally its deformation
• Grade V – a severe twisted septum with dorsal deviations
expressed externally and associated with bony vault
deformity [28]
From our point of view, an additional examination by a
glass stick is indicated to detect functional problems. With
this instrument a widening of the anterior valve can be simu-
lated and the patient immediately feels an improvement of
breathing. The stick can also simulate a batten graft by press-
ing it from the interior side to the ala so that the ala becomes
stiff. Compressing the base of the columella with a forceps is
also helpful because this maneuver detects the functional
problem of a wide columella.
W. Gubisch and J. Eichhorn-Sens
Such an analysis will result in a detailed, precise diagno-
sis as the fundamental tool of developing an individual surgi-
cal concept.
9 Operative Techniques
Preoperatively the patient is given a decongesting nasal gel.
In all cases, general anesthesia is provided. The patient is
positioned, prepared, and draped in standard fashion.
Routinely, we always give a local infiltration to the auricle if
it is decided during the surgery that a conchal graft is neces-
sary. After removing the vibrissae with a No. 15 blade, we
start to inject the external nose as well as the internal nasal
septum with 0.2 robivacaine hydrochloride and epinephrine
(Naropin®) followed by topical cocaine hydrochloride–satu-
rated cotton pledgets.
In twisted noses we always use an open approach with a
standard midcolumellar incision, in an inverted V fashion.
We start with an infracartilaginous incision and we dissect
the tip first because from our point of view this sequence
seems to be faster than to start with a columellar transection.
After dissection of the tip we cut the columella at the most
narrow part of the columella, avoiding any injury to the ante-
rior edges of the medial crura. Then we lift up the dissected
flap with an Aufricht elevator, dissecting the dorsum in a
submuscular plane (under the SMAS). The SMAS of the
nose is not identical with the SMAS in the face, but the mus-
cles in the nose are called SMAS [32].
Reaching the bony part of the dorsum, we incise the peri-
osteum with a knife and lift it up, so that we include the
periosteum with the soft tissue coverage.
Incising the periosteum has to be done very carefully
because there is always a chance of cutting the upper lat-
eral cartilages from the bone and creating an inverted-V
deformity.
After dissection of the dorsum it is necessary to decide if
a lowering of the dorsum is appropriate. If there is no hump
removal necessary we use the split technique [28].
Before separating the upper lateral cartilages from the
septum we do an extramucosal dissection of the junction of
the border between the dorsal septum and upper lateral carti-
lages and maneuver the valve area. The easiest way for that
maneuver is from our point of view the use of a rotatable
septum suction elevator (originally developed by Haraldsson)
(Fig. 1). If a hump reduction was planned the same maneuver
is performed without separation of the cartilages to perform
an en bloc resection the hump. Therefore, we perform a hori-
zontal lowering of the cartilaginous dorsum, cutting the
upper lateral cartilages and the dorsal septum horizontally
with a No. 11 blade. Now we have a new plane corresponding
The Twisted Nose
to a new dorsal line. In this plane we put our nasal chisel and
cut the bony part. Then the hump can be taken out in one
block. The chances of taking out too much bone are mini-
mized using this technique, but there is always the possibility
that not enough bone is taken. Therefore, it may be helpful to
hold the chisel not exactly horizontally, but to use the instru-
ment with an angle of about 10°. If there is minimal bony
excess after removing the hump this can be rasped down eas-
ily either with a sharp rasp or with a bur.
If dorsal hump resection is planned, the orientation of the
nasal bones must be considered, especially if there is an
asymmetric deviation (Fig. 2). Often, the nasal bone at the
side of the deviation is oriented more vertically. An asym-
metric preservation of the more vertically orientated nasal
bone will prevent excessive reduction on nasal bone height
of that side and produce a symmetrical shape and position.
Now starts the dissection of the septum, which is much
easier from above that from anteriorly. After reaching the
right plane, which means the subperichondral plane (you dis-
sect off the outer perichondrium; the inner perichondrium
Fig. 1 We use a rotatable septal suction elevator for submucous dissec-
tion of the cartilaginous septum
Fig. 2 The removal of the hump
must be done obliquely to perform
less reduction on the side of the
more vertically orientated nasal
bone. After the lateral osteotomies
the nasal bones are symmetric. The
yellow and the red line show the
correct and the wrong osteotomy
691
cannot be dissected off), you can dissect with a suction ele-
vator as mentioned above. You dissect both upper tunnels
until you reach the premaxillary/vomerine groove. These are
very strong connective tissue fibers and we recommend to
dissect off the anterior spine, to dissect the periosteum at the
lower tunnel, and to dissect the mucosa in this region with a
Mc Kenty periosteal elevator. After completing the dissec-
tion of the upper and the lower tunnels, the adhesive fibers
are cut with a round knife. After connecting both tunnels on
both sides we can precisely analyze the deformity and start
to develop a surgical plan of correction.
The most important point that affects the outer frame of
the septum is whether the L-shaped framework is straight or
the outer framework deformed In most twisted noses the
framework is not straight. A straight septal framework is the
prerequisite for a straight nose. Therefore, all efforts have to
be undertaken to straighten the septum.
The principles for correction of the deviated septum are as
follows:
1. Scoring of the septal cartilage (Fig. 3a): this is only prom-
ising in a mild deformity of the septum. This technique
exploits the tension forces of the cartilage, which means
that after unilateral scarification the contraction forces
outweigh to the other side. From our experience, it is not
uncommon for relapses to occur. To prevent these, there is
the opportunity to fix another straight cartilage or a
thinned and perforated piece of the septal bone at the
scarified anterior cartilage to straighten it permanently
(Fig. 3b, c). Alternatively, suturing of a curved cartilagi-
nous graft on the convex side of the remaining septum
will then act as a “counterspring” to prevent deviation
[33].
2. The so-called SMR (Killian procedure): resection of the
central septum, described by Killian more than 100 years
before [34], may improve the function, but will rarely
result in a straight nose. The Cottle technique to straighten
692
Fig. 3 (a) Scoring of the septal cartilage with a No. 15 blade. (b) A
piece of the septal bony part is thinned out and perforated with a drill.
(c) The thinned and perforated piece of septal bony part is fixed to the
scarified anterior cartilage to straighten it permanently
the septum involves reimplantation of the septal cartilage
after straightening.
3. Partial replantation: if possible try to preserve the septum
as far as it is straight and resect only the deviated parts,
this means that you perform only a partial straightening,
with partial repositioning [28]. So you can fix a newly
reconstructed anterior septal part to the rest of the pre-
W. Gubisch and J. Eichhorn-Sens
served straight septum. However, we often saw problems
that during the paramedian or the curved transverse oste-
otomies, in which the preserved straight part of the bony
cartilaginous septum broke off and then we had a worse
situation than before. Therefore, in severely deviated sep-
tal cartilages we prefer the extracorporeal septal recon-
struction, which means we take out the whole septum.
4. Extracorporeal septoplasty in a severely deviated septum.
We take out the whole septum in one piece, which means
the cartilaginous as well as the bony part and do a recon-
struction of a straight septum as we suggested originally
27 years ago, which means an extracorporeal septum
plasty or septal reconstruction [35]. In very badly
deformed and fractured cartilage it is possible to recon-
struct a neoseptum by suturing the straight parts of the
cartilage to a polydioxanone (PDS) foil or a thinned per-
pendicular plane.
5. In cases where the remaining septal cartilage is insuffi-
cient you can use either conchal or costal cartilage to
build a straight columella strut and/or a straight L-shaped
septum. In rare cases we resort to using thin sheets of
Medpore.
In summary, no one single operative technique alone is
always the best solution for the various deformities of the
nasal septum. The goal is to find out the best procedure for
the individual case to restore function and correct deviation.
9.1 Extracorporeal Septoplasty
We measure the necessary length of the dorsum as well as
the anterior length border of the septum and try by different
techniques to reconstruct a straight septal plate or at least a
straight L-shaped framework with the needed dimensions.
After taking out the deformed septum there are all kinds of
possibilities to reach this goal.
The first step is to smooth out all irregularities as much as
possible, especially thinning the part of the junction from the
bone to the cartilaginous septum that is thickened. This will
take away any spur and eliminates any deformities.
Now, the rest of the septum can be placed into a position
that allows getting the dimensions needed for reconstruction.
Very often, it is possible by rotating the straight septum parts
to get a residual septum that is straight in itself (see Fig. 6d–f).
In cases with multiple fracture sites and cartilaginous frag-
ments healed in dislocation, the puzzle technique means you
cut out small straight pieces and reconstruct a neoseptum of
the appropriate dimensions by suturing parts to a polydioxa-
none (PDS) foil (see Fig. 6g) or a thinned perpendicular
plane to provide a template for suturing and stabilizing
cartilaginous pieces. PDS foil or thinned bone may be also
The Twisted Nose
helpful in cases of very severely bent cartilages, which need
to be straightened by scoring or by thinning from the con-
cave side, but which may become soft and unstable with this
procedure. To overcome this instability, smoothly contoured
pieces of the perpendicular plate or PDS foil may be sutured
onto the cartilaginous septum.
The use of PDS foil in animal experimental work by
Fuchshuber [36] found that cases with a defect of the mucosa
by replantation of the PDS foil caused 10 % septal necrosis,
and 42 % of abscesses developed a massive perforation of
the septum, but in 58 % there was no cartilage defect, and a
healing without complications. In cases without a mucosal
defect, only 12.5 % developed a perforation of the septum
and in 87.5 % there was a healing without complications.
Therefore, in using PDS foil for reconstruction it is very
important to have no tearing of the mucosa.
For easier fixation, it makes sense to drill as many holes
as possible into the perpendicular plate. Furthermore, con-
nective tissue can grow into the holes in the bone, which is an
additional factor for stabilization.
After straightening the septum passed by switching the
posterior part to the anterior or creating a straight L-shaped
framework, we have to replant and fix the neoseptum. The
stable fixation of the replanted septum is essential for perma-
nent success – aesthetically as well as functionally. The easi-
est situation is when there are short nasal bones and long
upper lateral cartilages – you can hang the repositioned sep-
tum to the upper lateral cartilages by multiple quilting
sutures. For this procedure, we use straight 12 mm needle
with 4.0 resorbable or nonresorbable sutures. If in contrast to
that situation the nasal bones are long and the upper lateral
cartilages short, it is necessary to make drill holes into the
nasal bones to fix the replanted septum to the nasal bones and
bridge safely the keystone area. A second fixation point is
needed to prevent the replant from slipping. Therefore, the
septum has to be fixed to the anterior spine in the midline.
There are two options to correct a deviated anterior spine: if
the spine is wide and has dislocated the midline you can per-
form an asymmetric bony reshaping of the anterior spine
with a drill, so that the rest of the spine stays in the midline.
Then you can perforate this anterior spine (Fig. 4), drill a
groove into the premaxilla, adapt the length of the anterior
septum, and fix it to the bone.
In cases where dislocation of the anterior spine is more
than 3–4 mm, it is necessary to fracture the spine and bring it
into the midline. We fracture it usually trying to cut not only
the spine itself but also the premaxilla to bring the whole
structure into the midline and fix it there with a micro plate
and screws. We believe that this is a the prerequisite to keep
the replanted septum permanently in the midline, which
again is the prerequisite for symmetry of the nasal entrances
and the nasolabial complex. The septum is fixed to the ante-
693
Fig. 4 A drill perforates the anterior spine, so that the septum can be
fixed at the drill hole with permanent sutures
rior spine by multiple sutures in different levels so that there
is no chance of slippage. Fixation only to the periosteum,
from our point of view, is not sufficient.
If there is not enough cartilage left, especially if during
previous operations a lot of cartilage has been removed, the
bony parts of the septum may be sufficient to guarantee a
straight nose with a good profile. For that reason the bone is
drilled very thinly and at the anterior part we use an auricular
sandwich graft as a columella strut, so that the columella
itself is not stiff.
Thinning of the bone is performed most easily with a
cylindrical power drill. Additionally, it is necessary to perfo-
rate the bone with multiple drill holes. This has three advan-
tages: First, it is much easier to fix the septum through the
bone in a through-and-through manner because with more
holes you have more chances to use such a hole for fixation.
Second, we stabilize the septum with multiple mattress
sutures through the septal mucosa, and there you have to
detect these holes blindly again. Thirdly, there is an addi-
tional factor for postoperative stabilization with tissue
ingrowth.
In all cases of septal reconstruction, we suture spreader
grafts or extended spreader grafts to the dorsal part of the
new septum to restore the integrity of the internal nasal
valves, to restore the dorsal aesthetic lines, and to increase
the stability of the framework at the same time.
In revision cases, it is often not enough to straighten the
cartilage or bony material to create an L-shaped framework.
In this case our first option is to harvest conchal cartilages
from both ears and use it as a double layer sandwich graft
(Fig. 5). From our point of view this is the best option for a
straight anterior border of the septum. The graft will be fixed
to the anterior spine, and it is mostly possible to connect this
sandwich graft to the dorsal frame of the septum to create a
stable construct. All the remaining cartilage and bone that
694
Fig. 5 With the modified Aiach forceps the transplant can be put
together into an ideal position in which it is temporarily fixed with
small cannulas. A running suture is used for the final fixation
you have and do not need elsewhere should be smoothed out
and replanted between the mucosal sheets. Additionally, we
use transseptal mattress sutures and intranasal septal silicon
e splints. The splints are kept in place for 2 weeks. At the end
of the operation, a plaster of Paris is applied, which we also
leave for a total of 2 weeks.
The correction of a twisted nose is always a complex pro-
cedure. Therefore, the question comes up if the necessary
osteotomies should be performed before or after replanta-
tion of the newly reconstructed septum. From our point of
view, this depends on the width of the bony vault. If there is
a big hump to be resected at the beginning of the procedure,
it is much easier to do the osteotomy for narrowing the nasal
bridge before the replantation of the septum. If the bony
wall is not wide, you can first perform septal replantation
because the fixation to the upper lateral cartilages, and if
necessary to the nasal bones, is easier if they are fixed and
not mobile.
The experience of extracorporeal septoplasty showed
constantly good functional and aesthetic results. Gubisch
[35] found in a retrospective study with 2,301 patients, who
underwent extracorporeal septoplasty technique from 1981
to 2004 with a 1- to 6-year follow-up examination of 404
patients, that in 92 % the septum was central and straight
and 96 % considered their nasal breathing to be good or
excellent [35].
9.2 Submucosal Reduction
of the Hypertrophied Turbinate
The straightening of the septum may lead to airway prob-
lems if inferior turbinate hypertrophy is present because a
septal deviation may lead to compensatory contralateral infe-
rior turbinate hypertrophy. In these cases we perform submu-
cosal reduction of the hypertrophied turbinate bone if needed
after correction of the deviated septum.
W. Gubisch and J. Eichhorn-Sens
9.3 Osteotomy
The technique of mobilization by osteotomies depends on
the shape of the bony structures. In a very wide nasal bridge
we prefer straight transverse and straight low-to-low lateral
osteotomies after a paramedian osteotomy. The paramedian
osteotomies are required to allow independent movement of
the nasal bones. These osteotomies were done with a motor
drill because this is more accurate, and at the same time a
removal of the bony triangle at the most cranial point of the
junction of the nasal bones can be performed [35]. In smaller
bony vaults we prefer curved osteotomies, which means an
oblique transverse osteotomy combined with a low-to-high
lateral osteotomy. All osteotomies are performed transcu-
taneous with a 2 mm osteotome because the angle of the
instrument to the bone is almost perpendicular, using a trans-
cutaneous direct approach. This helps to avoid multiple frag-
ments, which might later cause irregularities.
9.4 Correction of the Nasal Tip
Almost all twisted noses implicate also a tip correction because
by the asymmetry of the dorsum and the deviation of the axis
there always results an asymmetry of the tip. This should be
corrected with well-known techniques. If the lower lateral car-
tilages are thin to medium sized a suture technique is always
our favorite. In thick cartilages it might be better to perform
a dome division and then to suture the cartilages against each
other as recommended by Kridel [37]. Depending on the indi-
vidual situation, it might be necessary to use additional grafts
for contouring the tip. In all cases we control the flaring of
the lower lateral cartilages, with a spanning suture, which we
hang to the dorsum of the septum with a suspension suture.
In cases where the classical spanning suture combined
with a suspension suture leads to a deformity of the lower
lateral cartilages, we fix the tip to the cartilaginous dorsum
by a modified suspension suture. This means that we fix the
5–0 nonresorbable suture to the dorsum, take it around the
medial crura to bring it back and to fix it without any tension
to the lateral crura.
Often, in twisted noses there is an asymmetry in the length
of the LLC (lower lateral cartilage). To get symmetry we use
either a unilateral sliding technique or do a unilateral short-
ening after dome division.
In all these complex procedures of reconstruction or
reorientation of a twisted nose, it seems necessary to smooth
out the dorsum in order to avoid postoperative irregularities.
As an onlay graft, material from the cartilaginous septum
The Twisted Nose
may be used or in the case of removing a hump it is possible
to thin out the hump and put it back to camouflage all irreg-
ularities. Mostly, we use an allograft of fascia lata, which
can be used not only as a one layer onlay graft but also as a
two- or three-layer implant depending on the individual
situation. Using this technique we have very good results
even in very severely deformed frameworks of twisted
noses.
9.5 Complications
Most complications are relapses of the deviation. Beneath
the inadequate corrected septal deviation inadequate oste-
otomies are the cause of this. If the lower two-thirds of the
nose are not straightened, the axis of the nose may shift
back toward the primary deviation, because of the memory
of the cartilaginous structures. Inadequate osteotomies may
result in a greenstick fracture, causing the bony nasal vault
to deviate during the postoperative period [38]. After divid-
ing the upper lateral cartilage from the nasal septum without
an adequate refixation, collapse of the upper lateral carti-
lages with subsequent compromise of the nasal valve may
occur [38].
10 Case Analysis
Case 1 Analysis A 37-year-old patient presented with a his-
tory of 4 previous operations elsewhere. There was an
extremely deviated nasal deformity to the right and a
depressed right nasal bone (Fig. 6a). The nasal dorsum was
overprojected in the lateral view, and the nasolabial angle
was too small (Fig. 6b). Additionally, there was a concavity
of the lower lateral cartilages (LLC) on both sites. From the
basal view he had a deviated columella, an asymmetry of the
nostrils and of the nasal tip (Fig. 6c). On internal exam, the
septum was extremely deviated, so that the right airway was
closed, and the turbinates of both sides were too big.
Surgical Technique
1. An open approach was done with a standard inverted-V
midcolumellar incision.
2. Analysis showed a deviated rib graft instead of septal
cartilage (Fig. 6d).
3. Conchal cartilage from one site was harvested.
4. Submucous turbinectomy was performed on both sides.
5. A conchal double layer graft (sandwich graft) was used
as a free-floating strut at the columella (Fig. 6e, f).
695
6. Reconstruction of a neoseptum was performed by sutur-
ing the straight parts of the conchal cartilage to a
polydioxanone (PDS) foil (Fig. 6g, h).
7. Correction of the concave deformed lower lateral carti-
lages (Fig. 6i, j) was performed with ala turn over
method (ATOM) in which the cephalic rim of the LLC
was incised, turned over and sutured together (Fig. 6k).
8. Correction of the nasal tip by a dome division technique,
transdomal sutures, a spanning suture, and finally a soft
tissue cap graft.
9. The bony vault was straightened with a low-to-low lat-
eral osteotomy after a paramedian osteotomy.
10. To avoid postoperative irregularities of the nasal dorsum
we used an allograft of fascia lata as one layer onlay
graft.
11. Closure of all incisions.
At 1 year, the nose is straight and respiration is normal. In
the basal view the nostrils and the nasal tip are symmetrical
and the columella is straight. In the lateral view the dorsum
and the nasolabiale angle showed a stable result (Fig. 6 l–n).
Case 2 Analysis A 20-year-old female requested correc-
tion of her deviated nose, bulbous tip and a nasal obstruction.
The patient denied any previous nasal trauma or surgery, but
on physical examination it was obvious that she must have
had nasal trauma which she could not remember. There was
a nasal deviation with the bony vault to the right, then a
curve of the cartilaginous vault to the left (Fig. 7a). The nasal
tip was too broad and underprojected. In the lateral view the
bony dorsum was overprojected (Fig. 7b). On internal exam,
the turbinates of both sides were too big and the septum was
extremely deviated. In the basal view you can see obstruc-
tion of the right airway, and the columella was deviated to
the left (Fig. 7c).
Surgical Technique
1. An open approach was done with a standard midcolumel-
lar incision.
2. Minimal reduction of the bony and cartilaginous dorsum
was performed.
3. Analysis showed an extremely deviated septum, so that
an extracorporeal septoplasty was performed. The septum
showed an old fracture, healed in dislocation (Fig. 7d, e).
After resection of the deviated portion, the straight sep-
tum part was 1 rotated 180°. The resected part was used
as spreader grafts (Fig. 7f).
4. A straight columella strut from septal cartilage was
implanted.
696
a b
d e
g h
i j
Fig. 6 Analysis: A 37 year old patient presented with a history of 4
previous operations elsewhere. There was an extremely deviated nose
deformity to the right and a depressed right nasal bone (a). The nasal
dorsum was overprojected in the lateral view, and the nasolabial angle
was too small (b). Additionally, there was a concavity of the lower lateral
cartilages (LLC) on both sides. From the basal view he had a deviated
columella, asymmetry of the nostrils and nasal tip (c). On internal exam-
ination the septum was extremely deviated so that the right airway was
closed and the turbinates bilaterally were too big. Surgical technique: 1.
W. Gubisch and J. Eichhorn-Sens
c
f
k
An open approach was done with a standard inverted-V mid columellar
incision. 2. Analysis showed a deviated rib graft instead of septal carti-
lage (d). 3. Conchal cartilage from one side was harvested. 4. Submucous
turbinectomy was performed bilaterally. 5. A double layer conchal graft
(sandwich graft) was used as a free-floating strut at the columella (e, f).
6. Reconstruction of a neoseptum by suturing the straight parts of the
conchal cartilage to a polydioxanone (PDS) foil (g, h). ATOM (ala turn
over method) (i, j) cephalic rim of the LLC was incised, turned over and
sutured together (k) post operative results (one year) (l-n)
The Twisted Nose
l m
Fig. 6 (continued)
a b
Fig. 7 Analysis: A 20 year old female requested correction of her devi-
ated nose, the bulbous tip and a nasal obstruction. the patient denied any
previous nasal trauma or surgery but on physical examination it was
obvious that she must have had nasal trauma in the past that she could not
remember. There was a nasal deviation with the bony vault to the right
and a curve of the cartilaginous vault to the left (a). The nasal tip was too
broad and under projected. In the lateral view the bony dorsum was over
projected (b). On internal exam, the turbinates of both sides were too big
and the septum was extremely deviated. In the basal view you can see the
obstruction of the right airway and the columella is deviated to the left
697
n
c
(c). Surgical technique: 1. An open approach was done with a standard
mid columellar incision. 2. Minimal reduction of the bony and cartilagi-
nous dorsum was performed. 3. Analysis showed an extremely deviated
septum so that an extracorporeal septoplasty was performed. The septum
showed an old fracture, healed in dislocation (d, e). After resection of the
deviated part, the straight part of the septum was rotated 180◦. The res-
sected section was used as spreader grafts (f). 4. A straight columella
strut from septal cartilage was implanted. 5. Correction of the tip was
performed by cephalic rim excision of the LLC, transdomal sutures and
spanning sutures. Post operative results (one year) (g–i)
698 W. Gubisch and J. Eichhorn-Sens

d e f

g h i

Fig. 7 (continued)
The Twisted Nose
5. Correction of the tip was performed by cephalic rim exci-
sion of the LLC, transdomal sutures and spanning sutures.
6. Submucous turbinectomy was performed on both sides.
7. The bony vault was straightened with an oblique trans-
verse osteotomy combined with a low to high lateral
osteotomy.
8. Implantation of one layer allograft of fascia lata to the
dorsum and use of a shield graft was performed.
9. Closure of all incisions.
After 1 year, the patient’s satisfaction is high. The nose is
straight and respiration is normal. In the basal view the nos-
trils and the nasal tip are symmetric and the columella is
straight. The tip is well defined (Fig. 7g–i).
References
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 Profiloplasty
Carlo Cavina
1 Introduction
The term profiloplasty is now a common term, although its
significance is vague. It must be considered, however, as an
operation whose goal is the modification of a profile. Of
course, the most important profile is the facial one, and its
modification means to bring it back to a normal one. Of
course, it is not easy to establish a normal profile, as there is
no fixed criteria for that. [2, 3]
A normal profile, obviously depends upon sex, race, and
body structure; but the judgment has always been condi-
tioned by models of beauty that media, movies, television,
and press can impose on people. Obviously, the nose will
play an important role in the profile, so that rhinoplasty will
positively act not only on the nose, but on the whole facial
profile. Theoretically, rhinoplasty can be considered a pro-
filoplasty. However, most surgeons think that a true profilo-
plasty should include operating on more anatomic structures
of a region. The profile will then be modified in a more com-
plex way, since corrections are on more parameters.
2 Soft Tissues and Skeleton
Soft tissues can be a cause of unharmonic profile, although
this is a rare possibility. In particular, big lips will determine
an unnatural profile between the nose and the chin. Of course,
pathological conditions such as angiomas and lymphangio-
mas can be a cause of volume excess, but the same can be
obtained artificially with fillers, and if the “fullness” is too
much, it will give an unnatural and grotesque look.
The lack of harmony of the facial profile is usually caused
by skeleton anomalies; these are sometimes congenital, but
C. Cavina, MD
Dipartimento di Scienze Chirurgiche Specialistiche
Anestesiologiche, Università di Bologna, Bologna, Italy
e-mail: carlo.cavina@unibo.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_49
more often can be acquired [4]. The middle third of the facial
skeleton, the mandible, and the chin (which can be consid-
ered alone, even if it is part of the mandible), can be inter-
ested alone or in association. When the anomaly concerns
the mandibular arch and the lower portion of the maxilla, the
dental arches are involved too, and there might be problems
with dental occlusion [5, 6].
3 Diagnosis
Diagnosis is mainly clinical. Several deformities of the pro-
file related to facial skeleton are obvious and visible at clini-
cal examination. Even an anomaly of dental occlusion can be
easily diagnosed with an endo-oral examination.
A radiological evaluation is also important. Three RX
projections are important (laterolateral, posteroanterior, and
sagittal. It is also important to have models of the dental
arches, because this will allow a proper study of malocclu-
sion before surgery.
Cephalometry is very important for diagnostic purposes. It
is the only examination that can establish the skeletal anoma-
lies, the degree of skeletal anomalies, and it can also measure
tridimensionally the entity of the problems. Surgery is planned
upon cephalometry, in particularly for the slight movements
of bone pieces in the three spacial dimensions. Once osteo-
synthesis is achieved, skeletal parts are repositioned with nor-
mal relationships, which are typical of a regular profile.
4 Dental Occlusion
When osteotomies involve both dental arcades, it is impor-
tant that, after surgery, these structures get to a proper occlu-
sion. This is a basic condition for bone stabilization during
healing. It is also a basic condition to avoid recurrences, that
is movement of mobilized parts towards their initial position
(defeating in whole or in part the results achieved). That is
701
702 C. Cavina

why surgical planning is very important, and orthodontics
must anticipate surgery. The aim is to align the teeth of the
upper and lower arcades, and make sure that at surgery
occlusion is normal. Close collaboration between surgeon
and orthodontist is of utmost importance because the ortho-
dontist will have the responsibility of presurgical prepara-
tion of the arcades and maintaining the occlusion obtained
until complete bone healing has been achieved [1, 8].
5 Surgery
Obviously, correction of any part of the profile requires a
custom-made surgery. This is true for nose surgery, and for
surgery of the facial skeleton as well, which includes oste-
otomies, ostectomies, bone grafts, and rigid fixation.
Cephalometry will be of great help: it allows a correct plan-
ning of the operation, calculating how many millimeters the
bones should be moved. Compared with surgery of the soft
tissues, it is much more precise [1, 7–9]. Of course, the sur-
geon has the option of introducing slight variations to the
surgical plan, based on cephalometry. He can decide to lower
or slightly advance the chin or the maxilla to get a better
harmony (often depending on soft tissues on the skeleton).
6 Rigid Fixation
Rigid fixation is a basic tool in surgery of the facial skeleton,
it represents the most important innovation during the last
decades, so that now contention of mobilized skeletal bones
is easier and more secure. Miniplates and screws today are a
basic instrumentation necessary for this kind of surgery.
Although we must give credit to wires for having allowed
difficult operations during many years, these devices are now
used only sporadically. As a matter of fact, plates and screws
give stabler osteosynthesis, shorter operative times and, most
importantly, allow stable fixation of very small fragments,
which was impossible before [9, 10].
Results in surgery of the facial skeleton should give radi-
cal changes in external appearance, avoiding visible scars.
When a precise planning is followed, and proper material is
used, this is a rewarding surgery (Figs. 1, 2, 3, 4, 5, 6, 7, 8, 9,
10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22).

Fig. 1 (a, b) Often, there can be

a contemporary dismorphy of
a b
nose and chin, the two most
important prominences of the
profile. Mentoplasty and
rhinoplasty are in these cases
strictly associated. In this
particular case, where the profile
is hyper convex, nose and chin
are equally important in the
etiology. A classic rhinoplasty
and a “jumping” mentoplasty
could regularize the profile
Profiloplasty 703

Fig. 2 (a) Planning of a a

“jumping” mentoplasty. (b)
Rigid fixation with plates and
screws was enough to stabilize
the chin, transposed in front of
the mandible. (c) The radiologi-
cal control after several years
(and the removal of plates and
screws) shows a stable bone
healing

c
704 C. Cavina

Fig. 3 (a, b) After a very

a b
conservative rhinoplasty, chin
advancement can be obtained
with an implant. The profile is
then improved

Fig. 4 (a, b) In a long and

a b
retroposed chin, implants are
contraindicated. A “jumping”
mentoplasty is here compulsory (as
in Fig. 1). Postoperative results
shown is after 6 years, with a stable
result
Profiloplasty 705

Fig. 5 (a) Profile anomaly caused by retroposition of the lower third of the face. The advancement of the whole mandibular arch and of the chin
allows a normal profile
706 C. Cavina

a b

c d e f

Fig. 6 (a) Planning of a horizontal osteotomy of the maxilla (Le Fort I).
(b) After the osteotomy the maxilla is free to move in any direction. The
most frequent transposition (indicated) is forward, so that the lower part
of the middle third of the face and of the upper dental arcade is possible.
(c–f) planning of a sagittal osteotomy of the mandibular rami
(sec. Obwegeser-Dal Pont). This is the most used line of osteotomy
allowing, in most cases, a simple mandibular pushback and the treat-
ment for mandibular protrusions (progenism). The same osteotomy can
be associated, in several occasions, to maxillary osteotomies. The man-
dibular arch is free to get along with the maxilla and adapt to its
movements
Profiloplasty 707

a b

Fig. 7 (a, b) In this case a combined maxillary-mandibular osteotomy was carried out. The maxillary advancement was able to give a better
profile harmony compared to the one obtained with a simple mandible pushback (with a final flat profile)
708 C. Cavina

a b

Fig. 8 (a, b) Pre- and postoperative view after a combined maxillary and mandibular osteotomy (jumping mentoplasty). (c) occlusion before and
after orthodontic treatment and surgery. (d) Radiography showing the profile before and after the triple osteotomy
Profiloplasty 709

Fig. 9 (a, b) Before and after ostectomies of the mandible, maxilla and to get a perfect dental occlusion. (d) Radiographies before and after.
mental region. (c) The dental arcades after orthodontic treatment and 1 Note the small sliding osteotomy of the chin, which was able to deepen
year after surgery. Teeth were aligned and the arcades prepared in order the labial-chin angle
710 C. Cavina

Fig. 10 Planning and intraoperative images of a reduction mentoplasty. Resection of a part of bone is able to reduce verticality and protrusion of
the chin
Profiloplasty 711

Fig. 11 (a, b), A reductive

a b
mentoplasty (according to
planning as in Fig. 10) has been
associated in this case to an
advancement of the maxilla and a
retropositioning of the mandible

Fig. 12 (a, b) Here, a

a b
rhinoplasty has been associated
to the maxillary advancement
and to a retropositioning of the
mandible. This can be
considered a complete and
radical profiloplasty
712 C. Cavina

Fig. 13 (a, b) In the case of a long face, the vertical dimension of the maxilla. Often, there is the need for a reduction-advancement mento-
maxilla should be reduced, with an ostectomy, calculated on the basis plasty. (c, d) Pre- and postoperative radiographies in case of a long face
of the cephalometry. A mandibular osteotomy should also be done, so (as in Fig. 14)
that the body of the mandible can follow the upper movement of the
Profiloplasty 713

a b

Fig. 14 (a, b) A “Long face”, corrected as previously illustrated. Vertical reduction was 5 mm. The gummy smile disappeared

a b

Fig. 15 (a, b) Also in this “long face” case, correction was obtained with a triple osteotomy to have a vertical reduction with an harmonic profile
714
Fig. 16 (a, b) Planning for a “short face” operation. Here, there is an
indication for a vertical elongation of the maxilla, together with a man-
dibular osteotomy (that allows its lowering), and a vertical elongation
of the chin. (c) After the maxillary lowering, bone grafts harvested from
the calvaria are inserted in the newly formed space. Plates and screws
C. Cavina
allow the maxillary fixation in its new position (planned with the aid of
cephalometry). In the same way, after an osteotomy of the chin, bone
grafts are inserted to allow a vertical elongation. (d) Teleradiographies
pre- and postoperatively clearly showing the vertical elongation of the
whole face. Radiographies belong to the patient in Fig. 17
Profiloplasty 715

Fig. 17 (a, b) A typical short

a b
face before and after surgical
treatment following planning
indicated in the previous
figure. The profile changes
significantly

Fig. 18 (a, b) In this case of

a b
“short face”, after the three
corrective osteotomies (maxilla,
mandibula, and chin) a rhinoplasty
has been later done. The term
“profiloplasty” is here much
appropriate
716 C. Cavina

Fig. 19 (a, b) Planning of a high a b

osteotomy of the middle third of
the facial skeleton. In this case
the lowest part of the maxilla and
the dental arches remain stable.
Movement concerns the
orbito-maxillar-malar area. The
inferior orbital rim, together with
the anterior part of the zygoma, is
mobilized and advanced. The
highest part of the middle third of
the facial skeleton is moved
forward, as a drawer. Obviously,
bone grafts will be inserted in
between zygomatic osteotomies
and in the orbital floors. The
mandible is pushed back with
sagittal ostetomies of the
mandibular rami. (c, d) Pre- and
postoperative radiographies after
orbito-maxillo-malar osteotomy
(belonging to patient in Fig. 20)

c d
Profiloplasty 717

Fig. 20 (a, b) A dismorphy

a b
of the facial skeleton
corrected according to
planning indicated in the
previous figure. In these
cases, the surgical access is
via the lower eyelid, apart
from the endo-oral route.
There is more space for the
surgeon towards the orbital
floor, the lower orbital rim
and the zygomas

Fig. 21 (a, b) profiloplasty with

a b
a double osteotomy of the
middle third of the facial
skeleton. The first is high
(orbito-maxillo-malar), allowing
for advancement of zygomas and
lower orbital rims. The second
one is a le Fort I, allowing for
advancement of the maxilla and
dental arcade. It is often done
together with a mandibular
pushback and a sliding
genioplasty
718 C. Cavina

Fig. 22 The profiloplasty is

a b
condsidered to be optimal.
The various parts of the profile
are aligned in a harmonious way.
The retraction of the lower
orbital frame allows for the
correction of exophthalmos

6. Horay P, Deffrennes D (2003) Chirurgia delle disarmonie nasali. In:

References
1. Rees T, La Trenta G (1998) Chirurgia plastica estetica. Verduci
Editore, Roma
2. Zaoli G (1992) Rinoplastica estetica. Piccin Editore, Padova
3. Tebbetts JB (2007) Primary rhinoplasty. Mosby Publisher, St. Louis
4. Fortunato G, Nisii A et al (1998) La profiloplastica in chirurgia
ortognatica. Riv Ital Chir Plast 30(3):161–165
5. McCarthy J (1990) Plastic surgery. WB Saunders, Philadelphia
Encycl Med Chir – Chirurgia Plastica Ricostruttiva ed Estetica.
Editions Scientifiques et Medicales Elsevier SAS, Paris, 45–543, 37 p
7. Micheli Pellegrini V (2005) Rinoplastica. Atlante chirurgia plas-
tica. SEE Editrice, Firenze
8. Mathes SJ (2006) Plastic surgery, vol. II. Elsevier – W.B. Saunders,
Philadelphia
9. Andersson L, Kahnberg K-E, Pogrel MA (2010) Oral and maxillo-
facial surgery. Wiley and Sons, Hoboken
10. Haerle F, Champy M, Terry B (2009) Atlas of craniomaxillofacial
osteosynthesis – miniplates, miniplates and screws. Thieme, Stuttgart
 Part VI
The Eyelids
 History of Cosmetic Eyelid Surgery
Isabella C. Mazzola
1 Introduction
Closure of wounds represents one of the first gestures of sur-
gery. The priority is assigned to the repair of facial defects
and the birth of Plastic Surgery is usually associated to this
objective. In particular, restoration of the nose and eyelids is
very old. Some historians believe that it is as old as writing
[1]. In the present chapter, we review the evolution of correc-
tion of eyelid anomalies through the centuries, with particu-
lar emphasis on the cosmetic aspect.
In Mesopotamia – In Mesopotamia, the region between
the river Tigris and Euphrates (now approximately Iraq), the
cradle of the Sumerian civilization, medicine was well devel-
oped, although influenced by astrology and divination. During
the excavations of the Nineveh palace, a library containing
more than 30,000 clay tablets with cuneiform inscriptions,
written about 600 B.C., although texts dated around
2000 B.C., was discovered. Eight hundred of these tablets
were related with medicine. “If a man is sick with a blow on
the cheek, pound together turpentine, tamarisk, daisy, flour of
Inninnu … mix in milk and beer in a small copper pan; spread
on skin and he shall recover.” The Sumerian clay tablets rep-
resent the world’s oldest medical manuscript. This is the rea-
son why we are allowed to affirm that management of facial
and eyelid wounds is as old as writing [1]. Another tablet sug-
gested the use of dressing with oil for open wound [2].
Although surgery was certainly performed, clay tablets
do not mention any surgical procedure. In the King
Hammurabi Code, about 1700 B.C., surgical malpractice
was acknowledged with detailed laws: “If a physician car-
ried out a major operation on a seignior with a bronze lancet
and has caused the seignior’s death or he opened the eye
socket of a seignior and has destroyed the seignior eye, they
shall cut off his hand.” “If a physician carried out a major
I.C. Mazzola, MD
Klinik für Plastische und Ästhetische Chirurgie,
Klinikum Landkreis Erding, Erding, Germany
e-mail: riccardo.mazzola@fastwebnet.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_50
operation on a commoner’s slave with a bronze lancet and
has caused (his) death, he shall make good slave for slave.”
In Ancient Egypt – The Edwin Smyth papyrus, one of the
oldest medical and surgical text dating about 1650 B.C., tell
us about Egyptian surgery [3]. It describes 48 cases of surgical
nature, for example, wounds, fractures, dislocations, sores,
tumors, suggesting their potential treatment. Case No.10 con-
cerns the cure of a wound in the eyebrow: “After you sew him
you have to cover him with fresh meat the first day. If you find
this wound with its sewing slipped, you have to fasten it for
him with two lengths of cloth. You should treat him with oil
and honey every day until he gets well.” The description of
the case indicates how eyelid wounds were handled on emer-
gency in ancient Egypt, the way bandages were applied, and
finally the importance of postoperative assessment to care
potential complications, for example, wound breakdown.
In India – In the Samhita, a Sanskrit text on surgery attrib-
uted to Susruta and possibly dating 600 B.C., the descrip-
tions of many contemporary procedures are reported [4].
Within Susruta’s work, management of entropion, trichiasis,
ingrown eyelashes is included. Before surgery, a special diet,
including milk, oil, and soothing decoctions was given.
Then, with the patient seated and “the surgeon standing with
his face toward him,” “an excision in the form and size of
barleycorn” was made “in the eyelid horizontally parallel,
leaving two parts below the eyebrow and one part above the
eyelashes. The surgeon should then suture up the two edges
with horse’s hair. Honey and ghee should be applied.” If the
procedure was unsuccessful, “cauterization of the upper lid
or complete epilation has to be performed.”
In Rome – In Rome, surgery was well developed, at least
judging from the rather sophisticated bronze instruments dis-
covered in Pompei and now kept at the Naples National
Museum. Many of them were stored in travelling kits to be
used by surgeons for emergency or in the battlefields.
The two most representative figures of Roman Medicine
were Celsus and Galen. Galen wrote on head traumas, trephi-
nation for evacuating hematomas, and various types of
bandaging.
721
722 I.C. Mazzola

Aulus Cornelius Celsus (25 B.C.–50 A.D.) was probably

not a physician, but a writer from a noble family (Fig. 1),
author, about 30 A.D., of “De Medicina” (On Medicine) in
eight books. In book seven, chapter seven, ectropion, lagoph-
thalmos, ingrown eyelashes, and pterygium are described,
and their treatment is reported. “If the upper eyelid is
retracted and cannot cover the eye, a semilunar incision, with
the two horns downwards, is made just below the eyebrow
until the tarsal plate, without damaging it… The lower mar-
gin of the incision is undermined and released. To impair the
separated parts to be brought together, a tiny piece of cloth is
placed in the raw surface, favoring healing process in the
middle. Once the wound is repaired, the eye is covered nor-
mally.” For ectropion, Celsus suggests a similar operation.
However, in this case, the two horns of the semilunar inci-
sion should be oriented toward the maxilla and not towards
the eye, so as to facilitate lower eyelid elevation and eye clo-
sure. Senile ectropion is treated by using a fine cautery [5].
Celsus described also skin flaps for lip and earlobe repair;
thus, he holds a key role in the history of Plastic Surgery. He
is the first to have described the four cardinal signs of acute
inflammation, “redness and swelling with heat and pain”
(“Rubor et tumor, cum calore and dolore”). Celsus manu-
script was discovered in Milano in 1443, and printed for the
first time in 1478 in Florence [6]. “De Medicina” went
through more than 50 editions.

2 Plastic Surgery After the Decline

of the Roman Empire

Byzantine surgery – Oribasius (325–403 A.D.) wrote a collec-

tion of medical writings entitled “Synagogae Medicae” where
reconstructive procedures for cheek, nose, ear, and eyebrow
defects are described [6]. Paulus of Aegina (625–690 A.D.),
surgeon and obstetrician, was the author of a Medical
Encyclopedia (“Epitome”) in seven books. Book 6 deals with
surgery, and numerous procedures are accurately reported, for
example, tracheotomy, tonsillectomy, lip repair, etc. [7–9].
Seventeen chapters (from Chaps. 6, 7, 8, 9, 10, 11, 12, 13,
14, 15, 16, 17, 18, 19, 20, 21, and 22) are devoted to eyelids
and their management. In the case of upper eyelid retraction
(Chap. 10) Paulus suggests to divide the scar until the upper
eyelid is lowered and to maintain the edges of the wound
separated by means of a gauze to avoid recurrence. Ectropion
(Chap. 12) is treated in the following way. Two stitches are
applied close to the margin and the eyelid elevated upward.
Then the skin is incised with a knife and freed. If the eye-
lid resumes its natural contour and the everted margin turns
inside, the operation is considered successful. Otherwise, an
incision in the form of an inverted V is made on the midline of
the lower eyelid and continued toward both ends of the border.
The separated parts are then joined with two stitches so that
they form a vertical line (Fig. 2). Chalazion (Chap. 16) can be
Fig. 1 Supposed portrait of Aulus Cornelius Celsus (25 B.C.–50 A.D.)
removed from outside or inside depending on its appearance.
In the latter case, the eyelid should be everted and a horizontal
incision is performed to excise the chalazion.
3 The Middle Age
A. Arabian surgery – Arabian doctors came from different
nations such as Persia, Syria, Spain, etc. Their only com-
mon denominator was the language. The most represen-
tative figure was Abū-l-Qāsim or Albucasis (ca.
936–1013 A.D.), whose famous treatise, “Al Tasrif “(On
Surgery), was translated into Latin and first published in
1500. It was the first independent surgical treatise ever
written, the others being associated with medical texts.
It included more than 200 illustrations of surgical
History of Cosmetic Eyelid Surgery
a b
Fig. 2 Correction of ectropion according to Paulus of Aegina (625–690 A.D.). (a) Inverted V incision; (b) final result
instruments, for example, tongue depressor, tooth extrac-
tor, hooks, cauteries, etc., most invented by Albucasis
himself, with the explanation of their use [10]. Albucasis
reported removal of a wedge of skin from the eyelid asso-
ciated with relaxing incision in the conjunctiva and sutur-
ing the edges of skin together for treating entropion or
trichiasis. Similar to most Arabian surgeons, Albucasis
was a supporter of cautery, for different clinical applica-
tions, for example, management of wounds, cleft lip, and
also correction of upper eyelid drooping, nowadays
known as blepharochalasis. For this case he advocated
cauterization of the whole length of the eyelid, using a
semilunar cautery (vol. 2, chap. 15).
B. The founding of the Universities – The founding of the
Universities is one of the most important events in the
Middle Age. The oldest university, at least in Europe,
was at Bologna, established in 1088, followed by Paris,
Oxford, and Montpellier. In Bologna, medicine was
taught and cadaver dissection was accepted, thus sig-
nificantly contributing to the development of anatomy.
Mondino de’ Luzzi (1270–1326) was the first anatomist
to lecture directly in front of the cadaver. His best pupil,
Guy of Chauliac (1300–1368) from Montpellier, wrote
“Great Surgery” in 1363 [11]. Management of eyelid dis-
eases is extensively reported. Relaxation of upper eyelid
is surgically treated in the following way. An incision in
the shape of a leaf of mirth is made in the upper eyelid.
The skin to be removed is grabbed with the fingers. Once
established that the upper eyelid is sufficiently raised,
the skin is excised with scissors and the wound margins
immediately sutured.
723
4 The Renaissance
The year 1583 marks a great breakthrough in ophthalmology
and eyelid surgery with the publication of “Ophthalmodouleia,
das ist Augendienst” (Ophthalmodouleia, or the Service of
the Eyes) by Georg Bartisch (1535–1607), oculist to the
Elector August of Saxony [12]. The book constitutes the first
comprehensive treatise on the care and management of the
diseases of eye and adnexa, is embellished by dozens of
detailed, full page anatomical images of the eye, eyelid and
brain, as well as of surgical instruments. It shows numerous
procedures for removing skin tumors of the eyelids and cor-
recting different anomalies. Besides this, it includes the first
clinical illustration of blepharochalasis and baggy eyelid
(Fig. 3) and the report of an original technique for surgical
relief of the overhanging skin fold above the tarsus for cor-
recting blepharochalasis, using a curved clamp in the form of
a guillotine (Figs. 4 and 5).
5 The Seventeenth and Eighteenth
Century
During this period, of time numerous procedures were devel-
oped to reconstruct eyelid, or to correct ectropion. Aesthetic
operations were scarce.
In 1724, Lorenz Heister (1683–1758), the most outstanding
German surgeon of the first half of the eighteenth century and
one of the most prominent in Europe, published a richly illus-
trated book, “Chirurgie” (On Surgery), in 1718, which was the
most accepted and widely read texts throughout the medical
724
Fig. 3 Blepharochalasis and baggy eyelid (From G. Bartisch (1583) [12])
community, where he describes the common procedures
known at that time [13]. Correction of blepharochalasis is
shown using a method similar to that reported more than 130
years earlier by Bartisch (Fig. 6). Restoring eyelids to their nor-
mal shape became an accepted procedure, so that the Parisian
surgeon Pierre Dionis (1643–1718) in his treatise “Cours
d’Opérations de Chirurgie”, published in 1707 [14], included
a plate, which depicts an operating table with the instruments
necessary to perform eyelid operations (Fig. 7), whereas René-
Jacques Croissant de Garengeot (1688–1759) illustrates an
upper eyelid incision, using a fine scalpel, in his “Traité des
Opérations de Chirurgie”, issued in 1731 [15] (Fig. 8).
6 The Nineteenth Century or
the Golden age of Plastic Surgery:
The Beginning of Cosmetic Surgery
The great majority of plastic surgery operations were con-
ceived in the nineteenth century, this is the reason why this
period is recognized as the golden age of Plastic Surgery.
I.C. Mazzola
Fig. 4 First illustration of blepharochalasis correction (From
G. Bartisch (1583) [12])
Fig. 5 The instrument devised by G. Bartisch, in the form of a guillo-
tine, for excising the excess of upper eyelid skin
Significant improvements were also achieved in the field of
correction of ectropion. In 1866, the French surgeon Pierre-
Édouard Cruveilhier (1835–1906) summarized the different
causes of the disease, analyzed the various procedures avail-
able at that time and wrote a well-documented thesis “De
l’Ectropion” (On Ectropion) [16]. About the same period,
the Latvian Julius von Szymanowski (1829–1868) published
“Handbuch der operativen Chirurgie” [17], where besides
an array of plastic surgery operations for closing various
defects of the body, he describes an original technique for
History of Cosmetic Eyelid Surgery
a b
Fig. 6 Correction of blepharochalasis, according to L. Heister (1718). (a) Skin excision; (b) the instrument to perform the operation [13]
Fig. 7 The operating table with the instruments necessary to carry out
an eyelid operation (From P. Dionis (1707) [14])
ectropion correction, which is still used nowadays (Fig. 9),
with some improvements made by H. Kuhnt [18].
About the same period, the mechanism of upper eyelid
drooping and baggy lower eyelids was studied. In 1817, the
Viennese George Joseph Beer (1763–1821) in his Lehre von
den Augenkrankheiten als Leitfaden öffentlichen Vorlesungen
entworfen [19] was among the first to describe fat herniation
and eyelid ptosis due to excess skin.
J. Sichel [20] was concerned with the etiology and clinical
illustration of orbital fat herniation: “(fatty ptosis) is pro-
duced by a certain amount of fat deposited between the skin
and the orbicularis,…most often in continuity with cellular
orbital adipose tissue… Frequently this fat is located under
725
Fig. 8 Upper eyelid incision with a scalpel (From RJ. Croissant de
Garengeot (1731) [15])
the muscle and after the excision of a strip of fat it is neces-
sary to incise transversely and parallel in the direction of
these fibers to demonstrate the swelling and elevate it… The
eyeball appears flaccid and swollen and presents a tumor
even elastic on palpation. Most often this tumor is encircled
between the border adhering to the eyeball and its wide
transversal fold. Frequently it hangs in front of the lower
part of the lid in the form of a bulge or of weighty horizontal
sac. Its weight, more important than the simple skin fold,
makes the movements of the lid more difficult…”
One of the first surgical approaches to upper eyelid relax-
ation was by Baron Guillaume Dupuytren (1777–1835), the
most brilliant leader of surgery in France. With his numerous
726
a b
Fig. 9 Correction of ectropion according to J. von Szymanowski (1870). (a) The design of the incisions; (b) the final result [17]
activities, he still found time to study the problem. In the
second edition of “Leçons orales de Clinique Chirurgicale
faites à l’Hôtel Dieu de Paris” (Clinical lectures on sur-
gery delivered at Hôtel Dieu of Paris), compiled by two of
Dupuytren’s pupils and posthumously published [21], one
reads: “we should say a few words about edema of the eyelids
that, after having resisted all known means, produces such a
drooping of the skin of that region in the long run, that it falls
down in front of the eyeball and, more or less completely,
interferes with vision… As it has been said, all internal ther-
apeutic means and topical remedies praised in similar cases
are ineffectual. When he was consulted, on several occa-
sions, for lesions of this type, Mr. Dupuytren thought that
excision of a part of the distended skin would be necessary,
succeeded by a scar that would put an end to deformity. The
operation which one uses in this case is wholly analogous to
the one employed to remedy trichiasis.”
A few years later, Ernst Fuchs (1851–1930), Professor of
ophthalmology in Vienna, named the condition “blepharo-
chalasis” [22].
7 The Twentieth Century:
The Development of Cosmetic
Surgery
Cosmetic surgery developed at the turn of the century,
although its explosion occurred during the interwar period.
In the USA, Charles C. Miller (1880–1950), from Chicago,
regarded as an “unscrupulous charlatan” by some, or “the
father of modern cosmetic surgery” by others for having
published in 1907 “The Correction of Featural Imperfections”,
I.C. Mazzola
a pioneering work on aesthetic procedures, where facial oper-
ations, such as double-chin excision and upper eyelid modifi-
cations, were illustrated [23]. Miller wrote: “these conditions
may be easily overcome by simple surgical procedures,
which are performed painlessly.” Removal of excess of skin
was advocated, whereas baggy eyelid correction was not pop-
ularized. In the second edition, published 17 years later [24],
he made considerable improvements, at least judging from
the variety of incisions illustrated, more than 13! However,
despite the lower eyelid approach, no fat removal is reported,
only skin excision and no pre- and postoperative photo is sup-
plied, but only drawings (Fig. 10).
In 1911, Frederick S. Kolle (1872–1929) published
“Plastic and Cosmetic Surgery” the second book on cos-
metic surgery in terms of priority [25]. Under the heading
“wrinkled eyelids” he advocated the removal of “the redun-
dant or baggy tissue by excision… The superior line of inci-
sion in operations of lower eyelid should be made as close to
the tarsal line as is practical, so as to show as little of the
resulting scar as possible.” (Fig. 11). “In operations about
the upper lid a somewhat widened elliptical piece of skin is
excised with its inferior margin about one fourth to one half
inch above the tarsal line…”
Lyons Hunt (1882–1954) published in 1926 his results of
cosmetic operations of the eyelids, as a section of his book
on head and neck surgery (Fig. 12) [26].
On the other side of the Ocean, at the end of the First
World War, Paris became the center of Cosmetic surgery
with leading personalities, for example, Suzanne Noel,
Julien Bourguet, Raymod Passot and many others.
Suzanne Nöel (1878–1954) established a successful solo
practice in the very exclusive 16th arrondissement in 1923.
History of Cosmetic Eyelid Surgery 727

a b

c d

Fig. 10 Upper and lower eyelid incisions for removing the excess of skin (From Miller 1924. (a, b) Upper eyelid correction, pre- and postopera-
tively; (c, d) lower eyelid correction, pre- and postoperatively [24])

Her operations were simple, but effective, mainly related to
facial rejuvenation and entirely performed on an outpatient
basis. In 1926, she published “La Chirurgie Esthétique. Son
Rôle Sociale” [27], one of the first textbooks on this topic
and the first written by a woman (Fig. 13).
Julien Bourguet (1876–1952) became renowned for hav-
ing first described the transconjunctival approach for baggy
eyelid improvement in 1929 [28] and later in 1936 [29]
(Fig. 14).
Raymond Passot (1886–1933), added innovative tech-
niques for breast ptosis, abdominal, and facial rejuvenation,
and eyelid correction using Bourguet’s method. His book “La
Chirurgie Esthétique pure”, dating from 1931 [30], shows a
wide range of operations in the field of aesthetic surgery
(Fig. 15).
In Berlin, Jacques Joseph (1864–1934), the father of aes-
thetic rhinoplasty, was well known for his operations for
facial rejuvenation and eyelid correction The design of skin
728 I.C. Mazzola

Fig. 11 Correction of crow’s-feet and upper eyelid skin excision

according to Kolle 1911 [25]
b

removal for upper and lower eyelid, illustrated in Joseph’s

book, soon became the standard method [31] (Fig. 16).
In Vienna, Ernst Eitner (1867–1955) was among the firsts
to illustrate excision of fat herniation from lower eyelid [32]
(Fig. 17).
A great breakthrough in the knowledge of fat herniation
of the eyelids was provided in 1951 by S. Castañares, who
identified the fat pockets [33]. A great change in aesthetic
surgery operative techniques has taken place after the Second
World War and in recent years. Correction of upper and
lower blepharoplasty became more precise and sophisti-
cated. A good review of the literature on blepharoplasty and
cosmetic surgery is supplied by Dupuis and Rees [34], Fig. 12 Pre- and postoperative result of a patient operated on by
Stephenson [35], and Haiken [36]. L. Hunt for upper and lower eyelid correction in 1926 [26]
History of Cosmetic Eyelid Surgery 729

a b

Fig. 13 (a–c) Pre- and postoperative result of a patient operated on by S. Nöel for upper and lower eyelid correction (From: La Chirurgie
Esthétique (1926) [27])

a b

Fig. 14 (a, b) Pre- and postoperative result of a patient operated on by J. Bourguet for lower eyelid improvement with transconjuctival approach
[30]
730 I.C. Mazzola

Fig. 17 Eitner’s method of removing fat herniation from lower eyelid

[32]

Fig. 15 Title page of Passot’s textbook, published in 1931

Fig. 16 The design of skin excision for upper and lower eyelid (From Joseph 1931 [31])
History of Cosmetic Eyelid Surgery 731

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seinen öffentlichen Vorlesungen entworfen, vol II. Camesina, Vienna
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d’Ophthalmologie. Ann Ocul 12:187–208
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swellings. Am J Sem Lang Lit 47:1–25
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95:51–53
 Anatomy of the Orbitopalpebral Region

Paolo Persichetti, Stefania Tenna,

and Annalisa Cogliandro

1 Introduction
The orbitopalpebral region is a complex anatomofunctional
unit, formed by several structures to support, protect, and
assist the eye in performing the visual function.
In recent years, the traditional normal human anatomy of
the orbitopalpebral region has been revised and integrated by
numerous studies which have further defined the structure in
its static and dynamic functions.
Important changes, due to the physiological process of
aging such as tissue relaxations worsened by different exog-
enous factors such as ultraviolet radiation responsible for the
so-called photoaging, may occur along the years in all indi-
viduals. This chapter aims to point out the anatomical basis
of the orbitopalpebral region and systematically give the new
morphological concepts whose knowledge has become of
great significance for a correct surgical approach.
medial third and middle third of the upper edge is located the
supraorbital foramen through which pass the external frontal
nerve – also named supraorbital nerve – and the supraorbital
artery. In the middle part of the lower edge there is the infra-
orbital foramen from which exit the infraorbital nerve – also
named maxillary – and the vessels (Fig. 1).
The four walls are respectively the upper one or orbital
vault which consists of the orbital portion of the frontal bone
forward and of the little wing of the sphenoid backward; the
inferior wall or orbital floor formed from front to back by the
zygomatic bone, the maxilla and by the orbital process of
the palatine bone, the outer side or lateral wall formed from
front to back by the lateral edge of the orbital portion of the

2 Orbit

The orbit is a quadrangular pyramid-shaped cavity between

the upper and the medial third of the cranial bones, directed
downwards and inwards and containing in its anterior part
the eyeball. The dimensions are variable according to race,
gender, and age. The orbital cavity is bounded by a base, four
walls, and an apex. Its base corresponds with the anterior
opening; it has a quadrangular shape and consists of the fron-
tal bone at the top, the orbital part of the maxillary bone at
the bottom and the inner side, and the zygomatic bone at the
bottom and the outer side. At the boundary between the

P. Persichetti, MD (*) • S. Tenna, MD, PhD

Dipartimento Centro Integrato di Ricerca (C.I.R.),
Università “Campus Bio-Medico”, Rome, Italy
e-mail: p.perischetti@unicampus.it
A. Cogliandro, MD
U.O.C. di Chirurgia Plastica, Università “Campus Bio-Medico”, Fig. 1 The orbital cavity in frontal projection with the superior and
Rome, Italy inferior orbital fissures

© Springer Berlin Heidelberg 2016 733

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_51
734
Fig. 2 The roof of the orbit and the superior margin with the supraor-
bital foramen; note the relationship medially with the ethmoid sinus
frontal bone, by the orbital apophysis of the zygomatic bone
and the greater wing of the sphenoid; finally the inner or
nasal wall constituted forward reverse by the orbital part of
the maxilla, the lacrimal bone, the lamina papyracea of the
ethmoid and the outer surface of the body of the sphenoid.
The orbit is also related in the upper part with the anterior
cranial fossa, at the back with the middle cranial fossa and
the sphenoid sinus, inferiorly with the maxillary sinus, later-
ally with the temporal fossa and medially, through the eth-
moidal cells, with the nasal cavity. Further anatomical
landmarks are: the lacrimal groove which houses the lacri-
mal sac, located behind the orbital edge at the level of the
inferior inner corner and formed by orbital branch of the
maxilla and by the lacrimal bone; the superior orbital fissure
also named sphenoid fissure, situated between the small and
the greater wing of the sphenoid that gives passage to the
frontal, lacrimal, trochlear, common oculomotor, abducens
nerves, to the nasociliary branch of the ophthalmic nerve, the
sympathetic root of the ciliary ganglion and to the upper and
lower ophthalmic veins; and the inferior orbital fissure or
sphenomaxillary between the orbital portions of the maxilla,
the greater wing of the sphenoid and the zygomatic bone that
gives passage to the zygomatic nerve, the maxillary nerve,
the orbital branches of the sphenopalatine ganglion, as well
as to an anastomosis between the inferior ophthalmic vein
and the venous pterygoid plexus (Figs. 2 and 3).
Finally in the posterior side of the orbit at its apex, is located
the optic foramen followed by the optic canal, which has close
P. Persichetti et al.
Fig. 3 The orbital cavity in sagittal view that lets assess the prismatic
shape, the joint between frontal bones, cheekbone and jaw, the inferior
orbital fissure and the relationship in the upper part with the frontal sinus
relationships with the sphenoid sinus and occasionally with
some rear ethmoid cell. The optic nerve together with the oph-
thalmic artery, which is located below and lateral to the nerve
itself, passes through these structures.
3 Eyeball
The eyeball has an ovoid shape to the most anteroposterior
axis and occupies the anterior prefascial portion of the orbital
cavity, surrounded by the capsulo palpebral Tenon’s fascia.
It is covered forward by the eyelids, from which it is sepa-
rated by means of the conjunctival space (Fig. 4).
The fascial sheath of the bulb or Tenon’s capsule is a con-
nective and lamellar formation, which has in its main part the
shape of a hollow sphere. It adheres to the posterior hemi-
sphere of the eyeball and separates it from the adipose body
of the orbit; it extends forward, behind the conjunctival for-
nix, until the sclerocorneal margin and backwards it wraps
around the optic nerve. It is connected to the edges of the
orbit by means of a funnel-shaped extension through the
peribulbar adipose tissue. This connective funnel-shaped tis-
sue, thanks to a non-uniform thickness, very thin in some
points, allows the passage of the neurovascular structures
anteriorly. The capsule has a special relationship with the
ocular muscles forming a sheath such as a finger glove for
each of them. These sheaths, more developed forward,
thinner and transparent behind, are connected by a very thin
connective lamella in the peribulbar portion called
Anatomy of the Orbitopalpebral Region
Fig. 4 The eyeball contained in the anterior prefascial portion of the
orbital cavity
intermuscular membrane. The levator muscle of the upper
eyelid is wrapped by the Tenon’s capsule and crosses it to
move towards its termination.
The striated muscles that govern the eye movements are
all contained in the orbital cavity and are classified into two
groups: the rectus muscles (superior, inferior, lateral, and
medial) and the oblique ones (upper and lower) (Fig. 5). All
rectus muscles originate from a single tendinous formation at
the bottom of the orbit: the common tendinous ring or annu-
lus of Zinn, a funnel-shaped ring that surrounds the medial,
upper, and lower tract of the optic foramen edge. They are
stretched, ribbon-shaped muscles, narrower behind, and
wider forward where by means of a long, flattened tendon,
thin and wider than the muscular body, attach themselves to
the sclera at a short distance from the cornea. The biggest
and strongest is the medial rectus. The insertion line of the
rectus muscles is called spiral of Tillaux.
There are two oblique muscles: the upper one is the lon-
gest and thinnest of the ocular muscles; it arises with a short
tendon from the medial edge of the optic foramen and the
optic nerve sheath and is linked at the top of the orbit with
the insertion of the levator muscle of the upper eyelid. In
proximity of the base of the orbital pyramid it is transformed
into a cylindrical tendon that joins a fibrocartilagineous eye-
let, the trochlea, fixed to the dimple or the trochlear spine of
the frontal bone, where it is reflected to head sideways and
back towards the eyeball inserting on the sclera, in the super-
olateral part of the posterior hemisphere of the eye. The infe-
rior oblique muscle therefore is the shortest among the
muscles of the orbit. It arises from the anteromedial part of
the lower wall of the orbit in the jawbone below the fossa of
735
Fig. 5 The rectus muscles, superior and inferior oblique muscles
the lacrimal sac. It goes sideways, backward, and upward,
describing a loop around the eyeball and folding obliquely
from below the inferior rectus muscle, so that the two sheaths
adhere intimately (Fig. 5).
The thickenings, due to bundles of reinforcing of the
Tenon’s capsule and by means of which the ocular muscles
acquire a secondary insertion on the outline of the orbit, are
known as orbital or arrest tendons. The most developed
arrest tendon is the lateral rectus muscle, which joins on the
outer wall of the orbit at the level of the lateral retinaculum
near the tubercle of Whitnall. The orbital extension or arrest
tendon of the medial rectus muscle is inserted on the poste-
rior lacrimal crest, behind the deep insertion of the medial
palpebral ligament. The superior rectus muscle has two
orbital tendons that arise from the medial and lateral edge of
its sheath and are inserted in the upper, medial, and lateral
corners of the orbit. They also send numerous fibers to the
tarsus and the conjunctival fornix mingling in part with the
collateral expansions of the levator muscle tendon of the eye-
lid (Fig. 6). These relationships justify a sort of functional
solidarity between the superior rectus muscle and elevating
muscle of upper eyelid strengthened by the merger of the
sheaths of the two muscles, and explain why the upper lid is
lifted, when the superior rectus muscle is contracted making
the bulb rotate to the high.
In the area where the rectus inferior intersects with the
inferior oblique muscle, the sheath of the two muscles
appears thickened and sends prolongations towards the walls
736
Fig. 6 Origin and insertion of the superior rectus muscle, inferior rec-
tus, and levator muscle of the eyelid
of the orbit to form the lower transverse ligament (or suspen-
sory Lockwood’s ligament). It fits below the orbital margin at
equal distance from the orbital tendon of the lateral rectus
muscle and the orbital insertion of the inferior oblique mus-
cle and sends numerous fibers to the conjunctival fornix and
the lower tarsus; therefore, the contraction of this muscle can
also make the lower eyelid go downward. The arrangement
of these thickenings and extensions of the sheaths of muscles
helps to divide the eyelid fat compartments described below.
4 Adipose Body of the Orbit
Adipose body of the orbit is the name of the lobular mass of
adipose tissue that fills the so-called retrofascial loggia of the
orbital cavity, the part of the cavity that remains behind the
fascia of the bulb, between the periorbita and optical nerve
wrapped in its sheaths. The adipose body of the orbit is
crossed by the ocular muscles, surrounded by their sheaths,
by the vessels and nerves of the orbit and takes relationship
with the capsule that encloses the lacrimal gland. The main
mass of the adipose body is contained in the pyramidal space
limited by the ocular muscles, while it becomes thinner at the
level of the more superficial layer between the muscles and
the periorbita. The adipose body also persists, while decreas-
ing its volume, in very emaciated individuals, and because of
this feature it is considered “permanent fat.” Its reduction is
usually due to the loss of water by the adipose cells. The
sinking of the eye cannot go beyond a certain limit because
P. Persichetti et al.
of the resistance of the bulbar fascia. The main functions of
the intraorbital adipose tissue are those of protection, sup-
port, and reduced friction of the eyeball. The numerous lob-
ules in which the fat is subdivided by thin fibrous septa, are
oriented along the axis of movement of each connected
structures, thereby creating spaces of flowing (e.g., circular
around the posterior pole of the globe and the Tenon’s cap-
sule, longitudinal around their own muscles). These fibrous
septa are not independent of each other but they proceed and
are in continuity with the fibrous sheaths that cover the mus-
cles and the globe (Tenon’s capsule, capsulopalpebral fas-
cia); inside the septa there are small artery and veins. The
division of the adipose tissue by these fibrous septal forma-
tions enables it to modify its own shape in the presence of a
constant volume. This arrangement also determines the for-
mation of the adipose compartments of the eyelids.
5 Eyelids
The eyelids are musculocutaneous structures delegated to the
protection of the eyeball. They are commonly divided into
upper and lower. Each eyelid is anatomically divided into
two lamellae, one posterior and one anterior to the axis that
passes through it and connects the orbital septum and the
tarsus (Fig. 7, see also Chap. 55, Fig. 10).
The anterior lamellae consist of skin and orbicularis mus-
cle (with their own vasculo- neuro-fascial systems), while
the posterior lamellae include in addition to the fibrous skel-
eton, called tarsus, and the orbital septum, the levator palpe-
brae superioris muscle and the inferior retractors, as well as
the conjunctiva of the inner lining.
The eyelid skin is the thinnest of the human body (<1 mm),
it is more delicate than the surrounding tissues and due to
aging tends to atrophy losing elasticity and firmness. The
medial or nasal portion is characterized by numerous seba-
ceous glands and poor hair formations, pointing out the tran-
sition with the eyebrow skin superiorly and the cheek
inferiorly.
The subcutaneous layer, poorly represented, consists of
loose connective tissue, and is more evident in the lateral
third; adipose elements are rare and totally absent at the level
of the pretarsal subcutaneous tissue. The same subcutaneous
tissue lacks at the medial and lateral palpebral ligaments,
where there is a close connection of the skin with the under-
lying fibrous tissue.
The orbicularis muscle is one of the crucial muscles in
facial expression. It is part in its peripheral or orbital portion
of the superficial muscular aponeurotic system (SMAS) of
the face, whose contraction is reflected to the overlying
tissues due to fibrous septa that connect the muscles with the
dermis, resulting in facial expressions that characterize the
mankind. The muscle can be divided in a central or palpebral
Anatomy of the Orbitopalpebral Region
Fig. 7 Anatomy of the eyelids in sagittal section where the distinction
between anterior lamella (consisting of skin and orbicularis muscle)
and posterior lamella (comprising in addition to the fibrous skeleton
called the tarsus and the orbital septum, the levator palpebrae superioris
muscle and the retractor of the inferior eyelid, as well as the conjunc-
tiva) can be appreciated: lower eyelid
Fig. 8 The orbicular muscle can be divided into a central or palpebral
part and a peripheral or orbital one; the first portion is further divided
into a pretarsal and a preseptal part
part – contained within the limits of the orbital bone contour –
and a peripheral or orbital one; the first portion is further
divided into a pretarsal and a preseptal part (Fig. 8).
The orbital portion of the orbicularis muscle originates in
correspondence of the medial orbital rim where it acquires
insertions with both superior and inferior margins of the
medial palpebral ligament and the maxillary process of the
737
frontal bone; it widely extends in a circular way around the
orbit (such as a horseshoe), connecting with the other mus-
cles of facial expression (frontal muscle, corrugator, procer-
ous, major and minor zygomatic muscles), and extends
laterally to cover the superficial temporal fascia.
The preseptal portion of the orbicularis muscle lies super-
ficially to the eyelid orbital septum and its median origin
consists of a superficial end and a deep one associated with
the medial palpebral ligament. The fibers coming from the
upper and lower eyelid combine laterally forming the lateral
palpebral raphe, adherent to the overlying skin.
The pretarsal portion is located at the front of the tarsus
to the free margin of the eyelid, and its two heads of origin
(superficial and deep) are intimately associated to form the
medial palpebral ligament. The fibers are directed horizon-
tally and laterally under the lateral palpebral raphe to fit on
the tubercle of Whitnall on the lateral wall of the orbit about
2 mm from the bone edge, with interposition of the lateral
canthal tendon.
Inferiorly, the pretarsal portion of the orbicularis muscle
helps to form laterally the lateral canthal tendon, while in the
medial canthal tendon fibers converge from both the palpe-
bral and the orbital portion. At this level the eyelid part of the
orbicularis muscle splits and fits by a posterior tendon in the
posterior lacrimal spine. The lacrimal sac is so wrapped up
by the two heads of medial insertion of the orbicularis mus-
cle: this arrangement has a key role in the physiology of the
lacrimal apparatus with a suction action. The orbital part of
the orbicularis muscle is used in the forced closure of the
eyelid, while the palpebral portion is used in voluntary and
rapid closing of the eye and in blinking. Below the orbicular
muscle there is the areolar submuscular tissue, which contin-
ues upward until the eyebrow region where the fat pad of the
eyebrow is located (ROOF – retroorbicularis oculi fat), and
inferiorly continues in the malar fat pad (SOOF –
suborbicularis oculi fat). The orbitopalpebral septa are
fascial membranes starting from the edge of the orbital bone
in continuity with the periosteum and heading to the tarsal
laminas, placed transversely along the ciliary margin.
In the upper eyelid the orbital septum, the fascial mem-
brane that separates the anterior from the posterior lamina,
originating at the the top from the marginal arch, a fibrous
thickening placed along the the orbital edge where there is
fusion between the front and periosteum that covers the walls
of the orbit, while the bottom is inserted in the aponeurosis
of the eyelid elevator at the height, or slightly above, the
upper margin of the tarsus. It also gets fixed to the lateral
canthal tendon and to the posterior lacrimal spine medially;
hence the insertion line reaches in the anterior oblique direc-
tion the anterior lacrimal spine, and then the inferior orbital
rim, from which it detaches itself to be inserted further down
than the orbital margin, on the anterior face of the zygomatic
bone. The recess thus formed is filled by the infraorbital fat
738
Fig. 9 The adipose compartments of the upper and the lower eyelids
(recess of Eisler). The orbital septum is formed by connec-
tive multilaminar tissue; its elasticity and laxity allows the
mobility of the eyelid structures in the movements of open-
ing and closing. It is thinner in its medial portion which is
crossed by the neurovascular pedicles. This thinness can
cause greater tendency to the herniation of the eyelid fat in
this region. It also represents the anterior wall of preaponeu-
rotic adipose space, located between the aponeurosis of the
levator muscle and the periosteum of the orbital cavity, and
contains an important part of the infraorbital fat around the
eyes. Behind and in close contact with the posterior laminas
are the eyelid adipose compartments (Fig. 9). These fat
deposits are defined preaponeurotic because they are placed
in front of and above the aponeurosis of the levator palpebrae
superioris and in front of and below the capsulopalpebral fas-
cia in the lower eyelid. Three fat compartments have been
described at the level of the upper eyelid, a nasal or medial
compartment, an intermediate or preaponeurotic, and one
more lateral of the recent description, and three on the level
of the lower eyelid, medial, central, and lateral.
At the level of the upper eyelid, the medial or nasal com-
partment is contained between the medial canthal tendon
below, the tendon of the superior oblique muscle in the
superolateral position, the aponeurosis of the levator muscle
of the eyelid and the Whitnall ligament laterally and the fron-
tal bone in the medial direction. This fat with distinct charac-
teristics (it is lighter in color) represents the anterior extension
of superomedial prolongation of the body fat of the orbit,
while the central and lateral compartments, of a more intense
P. Persichetti et al.
yellow color, are a dependency of the preaponeurotic adi-
pose tissue (TAP).
At the level of the lower eyelid three compartments are
identified: medial, central, and lateral. The medial compart-
ment is separated from the central one by the horizontal
course of the inferior oblique muscle, while the central and
lateral compartments are separated in depth by the alar
extension (curved expansion) of the sheath of the rectus and
inferior oblique muscles.
The tarsal laminas are composed of dense fibrous tissue
and are responsible for the structural integrity of the eyelids,
acting as an internal stiff support.
The superior tarsus, in the manner of a crescent-shaped
curve at the bottom, presents a central maximum height of
10 mm, tapering in the medial and lateral direction. The infe-
rior tarsus, rectangular, reaches a central maximum height
of 3.5–5 mm. Each tarsus measures approximately 29 mm in
length and 1 mm in thickness. The rear surface of the tarsal
laminae is in contact with the conjunctival mucosa. Each tar-
sus contains about 25 sebaceous glands (of Meibomio), ori-
ented along the vertical axis, with the ducts which open at
the level of the free margin of the eyelid, just forwardly of
the mucocutaneous junction.
The lateral and medial peaks of each tarsus are connected
to the orbital rim through the medial and lateral canthal ten-
dons which will be described in detail subsequently.
At the level of the tarsus of the upper lid is inserted the
levator muscle of the eyelid which originates at the orbital
apex from the bottom surface of the small wing of the sphe-
noid bone, which is essential for the opening movement. This
muscle can be anatomically divided into two portions:
anterior and posterior; the former is thick, with a few smooth
muscle fibers, moves upwards and reflects some millimeters
above the tarsus to become contiguous with the orbital sep-
tum. The latter portion (posterior) is thinner, with a greater
number of smooth muscle fibers, merges with the subcutane-
ous tissue and with the lower third of the tarsus. The superior
rectus muscle and the levator muscle of the eyelid share their
origin of development, and are connected by fibrous branches,
especially at the sovrabulbar level, which are condensed in
the intermuscular transverse ligament (ITL). The ITL extends
longitudinally up to the superior conjunctival fornix and later-
ally to the lateral margin of the orbit situating below in sup-
port of the lacrimal gland. The upper transverse ligament or
ligament of Whitnall is located at the junction between the
muscle body and the aponeurosis, surrounds in a manner of a
sleeve the same muscle and represents a condensation of the
muscular fascia which transversely crosses the anterosuperior
orbit; it is inserted laterally at the level of the fascia of the
orbital lobe of the lacrimal gland with weak branches also
directed to the region of the lateral retinaculum (where the
lateral canthal ligament and the arrest tendon of the lateral
rectus muscle are inserted), and medially at the level of the
Anatomy of the Orbitopalpebral Region
Fig. 10 The superior transverse ligament or Whitnall’s ligament
crosses transversely the anterosuperior orbit and is inserted medially at
the level of the fibrous complex surrounding the trochlea
fibrous complex surrounding the trochlea (Fig. 10). Thin
fibrous branches join the ligament of Whitnall to the upper
orbital margin. The muscular portion is 40 mm long while the
aponeurotic part is about 15–20 mm and extends laterally and
medially to form two fibrous extensions. The lateral exten-
sion divides the lacrimal gland in the two lobes (orbital and
palpebral) before joining at the level of the tubercle of
Whitnall on the lateral wall of the orbit. The medial extension
is inserted to the posterior lacrimal crest.
The distal portion of the aponeurosis merges with the
orbital septum before being inserted at the level of the upper
tarsal edge. The distal margin of the merger continues with
some fibers on the anterior face of the tarsus while a second
share of fibers is inserted at the level of the overlying orbicu-
laris muscle until the pretarsal skin and creates the supratar-
sal crease.
Recently the lower portion of the transverse intermuscular
ligament (LPTL) and the ligament supporting the medial
extension (MHSL) have been further classified. The first,
which has less elasticity compared to the ligament of Whitnall,
arises from the anterior surface of the trochlea and is inserted
at the level of the lateral orbital margin with the support func-
tion of the preaponeurotic fat. The second also originates at
the level of the anterior surface of the trochlea but moves lat-
erally until the medial extension with reinforcement function
of the ligament of Whitnall to demarcate the medial margin of
the levator muscle of the eyelid. The muscle of Muller is a
smooth muscle innervated by the sympathetic nervous sys-
tem, whose fibers originate from the bottom surface of the
junction between elevator aponeurosis, pass in the plane
739
between the aponeurosis and the conjunctiva to be inserted to
the upper margin of the tarsus. Occasionally its fibers extend
to cover the upper two thirds of the tarsus. The virtual space
between the levator muscle of the eyelid and the muscle of
Muller is called “post-aponeurotic space.” Its action is to
extend the orbital fissure depending on the increased sympa-
thetic tone. Some studies suggest that there are fibers of the
muscle of Muller which are continuous with the Tenon’s fas-
cia interconnected with the intermediate peribulbar muscle so
that it must be considered not as an entity in its own but as
part of the complex of intraorbital muscles. In fact, the con-
traction of its fibers contributes in the order of a few millime-
ters to the elevation and maintenance of the tone of the upper
eyelid. At the level of the lower edge of the muscle of Muller,
immediately above the upper tarsal edge, there is the periph-
eral vascular arch of the upper eyelid.
On the contrary, at the level of the lower eyelid the tarsus
is smaller. In addition, the movement is very small and
almost null compared with that in the upper eyelid where the
actual existence of a system of active opening of the lower
eyelid is still discussed.
The lower tarsal muscle (inconstant – the opponent lower eye-
lid muscle of Muller), innervated by the sympathetic, also comes
from the inferior rectus muscle to be inserted on the tarsus.
The conjunctival mucosa covers the rear surface of the eye-
lid from the mucocutaneous junction of the free margin and
continues adhering on the inner wall of the tarsus and of the
muscle of Muller (superiorly) until you reach the arches,
where it flips to cover the anterior surface of the eyeball except
for the cornea.
The capsulopalpebral fascia is always constant – tendinous
prolongation of the lower rectus muscle, which after wrapping
the inferior oblique muscle, is combined to form the ligament
of Lockwood (or lower transverse ligament). It consists of
three parts: a lower, rectus muscle and an arcuate extension.
The origin is common at the posterior lacrimal crest – the lat-
eral insertion is at the level of the tubercle of Whitnall, 2–4 mm
posteriorly to the lateral eyelid rim.
The lateral canthal tendon is about 7 mm long and 3 mm
wide and it consists of the preseptal parts and the upper and
lower orbital portions of the orbicularis muscle which join
laterally to the outer canthus to form the eyelid raphe. The
raphe adheres partially also to the anterior surface of the
orbital edge so as to constitute part of the external branch of
the tendon.
On the contrary the pretarsal fibers are joined in a stron-
ger fibrous band (where there is also the tarsus) which goes
2–5 mm behind the lateral orbital edge in the tubercle of
Whitnall. At the top, the lateral canthal tendon continues
with the lateral extension of the aponeurosis of the elevator,
while the lower edge is well defined and clear. Together with
the lateral canthal tendon, on the orbital wall, in an area
called the lateral retinaculum, other important structures are
740
inserted such as the lateral extension of the aponeurosis of
the elevator, the suspensory lower Lockwood’s ligament and
the arrest tendon of the lateral rectus muscle.
The lateral retinaculum is a sheet of thick connective tis-
sue that maintains the integrity, the position, and the pressure
of the globe and the periorbita through its anchorage to the
lateral wall; it represents a sort of hook that suspends bulb
and eyelid. All structures of the lateral retinaculum converge
to fit on Whitnall’s tubercle. Moreover, the lateral canthal
tendon is inserted to the orbital border with superficial, deep,
upper, and lower fibers. The lower ones, starting from the
tarsus have recently been referred to as “tarsal strap.” The
orbital septum joins the orbital rim anteriorly to the lateral
canthal tendon (deep end) in close relationship with the pal-
pebral raphe – carried more superficially and following the
superficial teguments. Between the orbital septum and the
lateral palpebral ligament there is always a small fat pad
derived from the infraorbital adipose tissue – a useful surgi-
cal landmark to identify the tendon itself.
The medial canthal tendon is a fibrous structure that sta-
bilizes the medial tarsus and is intimately connected with the
orbicularis muscle and the lacrimal apparatus. The fibers
converge to the sturdy tendon from different portions of the
orbicularis muscle (the eyelid and orbicularis portions) that
fit into the anterior lacrimal crest, superficially to the lacri-
mal canaliculi (superficial end of the medial palpebral liga-
ment) (Fig. 11). The palpebral portion of the orbicularis
muscle (pretarsal and preseptal) forms the deep end of the
medial canthal ligament (or Horner’s muscle), which is
Fig. 11 The relationship between the orbicularis muscle with the cana-
liculi and the lacrimal sac
P. Persichetti et al.
inserted at the level of the posterior lacrimal crest and at the
fascia of the lacrimal sac. The lacrimal sac, surrounded by
his band, is thereby in relation with the constituents of the
canthal tendon in every direction, except medially, where it
is in relation to the lacrimal fossa.
6 Surgical Topographic Anatomy
of the Eyelid Region
The palpebral fissure is a fusiform space between the upper
and lower eyelid free margins; its dimensions are approxi-
mately 28–30 mm in length and 9–12 mm in height. This
opening is delimitated on each side by the lateral canthus
(about 5 mm from the orbital lateral edge) and the medial
canthus which forms the inner or nasal corner. In European
population, the medial canthus is located 2 mm below the
lateral canthus, while in Asians this gap can be up to 4 mm.
The natural curvature of the upper eyelid is the result of the
dynamic elastic force of the tarsal membrane adapted to the
globe curvature. In children, the margin of the upper eyelid
in opening is at the superior edge of the conjunctival limbus
(margin of the iris); in adults there is a slight lowering, up to
1–1.5 mm. The margin of the lower eyelid is located in cor-
respondence of the lower limbus (Fig. 12).
The upper eyelid sulcus is 8–12 mm above the ciliary
margin and is formed by the musculocutaneous insertions of
the fibers of aponeurosis of the upper eyelid levator muscle
which coincide with the junction between the septum and the
aponeurotic extension at/of the superior edge of the tarsus,
through the areolar submuscular tissue and fixed into the der-
mis. Skin, orbicularis muscle, aponeurotic extensions of the
elevator and tarsus are bound to one another. Above the tar-
sal lamella, skin, orbicularis muscle, and orbital septum are
the only support structures to the intraorbital content which
tends to form a prominence increasingly evident in the long
Fig. 12 Topographical anatomy of the eyelids
Anatomy of the Orbitopalpebral Region 741

run due to the effect of gravity and oldness that increasingly Finally, the groove of the septal confluence is the only one
weaken these structures. In eastern populations, the insertion not associated with an adhesion between skin and bone but is
of the aponeurotic layers in the dermis is situated lower than formed by the deep bond between septum orbitae, the retrac-
the upper tarsal margin and also the merger point with the tor ligaments of the lower eyelid and the tarsus. It is delim-
orbital septum is located on the anterior face of the tarsus. ited by a portion sometimes hypertrophic of the orbicular
The intraorbital fat is therefore able to fill this small antitar- muscle in its pretarsal portion above, and by the orbital fat
sal recess and determine the typical swelling of the upper inferiorly. The careful identification of these grooves allows
eyelid. At the level of the lower eyelid, the lower eyelid fold choosing the most suitable surgical technique to rejuvenate
or furrow is located at the inferior edge level of the tarsus. the entire region.
Sliding of the tissues in looking downward causes a flexure The accurate ophthalmological and orthoptic assessment is
of the very adherent and rigid skin in front of the tarsus and still a fundamental requirement to complete the preoperative
the laxer one that is below it. This groove, which is present evaluation for the definition of the correct surgical strategy.
especially in children, ranges from a minimum distance of
3 mm from the free margin of the eyelid in the medial region
to about 5 mm in the lateral region. 7 Gland and Lacrimal Apparatus
At the clinical examination of the eyelid region, the
amount of protrusion of fat is defined as “eyelid bag” while The lacrimal apparatus together with the eyelids and con-
the excess, relaxation and ptosis of the skin and orbicularis junctiva is part of the apparatus of eye protection. It consists
muscle is commonly called “blefarocalasis.” It is equally of the lacrimal gland and the lacrimal ducts, including the
useful to assess the position of the eyeball and identify a pos- tear ducts, the lacrimal sac, and nasolacrimal duct (Fig. 13).
sible protrusion or retraction thereof compared to the orbital The lacrimal gland, responsible for the reflex tear secretion,
cavity as it also affects the position of the eyelids. is located in the upper outer part of the orbital cavity. The
It is possible to simplify this assessment considering the tendon of the levator muscle of the upper eyelid, its lateral
“orbital vector,” defined as the theoretical line drawn from expansion and the lateral margin of the superior rectus mus-
the most prominent point of the eyeball to the infraorbital cle divide the gland into two portions: an orbital portion,
rim. When the eyeball is more advanced than the orbital more voluminous, located in the lacrimal fossa of the frontal
edge, the vector is “negative”; in case of matching, it is con- bone, between the periorbita and the lateral pillar of the leva-
sidered “neutral” while if the globe is more backward than tor (at the level of the third side of the preaponeurotic space);
the edge the vector is “positive.” and a palpebral part, placed between it and the conjunctival
It is important then to identify some grooves that may be fornix below. The excretory ducts of the two sides flow into
present in the lower eyelid, at the limit with the zygomatic the upper lateral conjunctival fornix. The tears are poured
region, and are normally expression of adherences between continuously into the conjunctival sac and collected in the
skin and bone structures. Three are normally the grooves that medial corner of the eye, in the region of the lacrimal lake,
can be highlighted: the orbital groove, the zygomatic groove,
and the groove given by the septal confluence. The orbital
groove corresponds to the orbital rim or orbito-malar liga-
ment, follows the circular contour of the lower orbital rim and
it is the groove that normally shows when there is an adher-
ence of the skin with the arcus marginalis in the presence of a
hypoplasia of the jawbone. This deformity also said “V defor-
mity” is often associated with a negative vector, and also man-
ifests itself with different degrees even in the presence of a
protrusion of the orbital fat above and of a ptosis of the sub-
orbicularis oculi (SOOF) fat and the fat pad of the cheek
below. Sometimes the medial portion is more accentuated and
corresponds to the “tear trough” described by Flowers.
The zygomatic groove corresponds to the orbito-zygomatic
ligament and more precisely to the insertions of the elevator
muscles of the upper lip and the zygomatic muscles, both
important to their relationship with the orbicularis oculi mus-
cle. The zygomatic groove is bounded by margin of the malar
bone in the upper part and by the lateral fat pad of the cheek.
It can sometimes join centrally with the orbital sulcus. Fig. 13 The lacrimal apparatus: the gland, the canaliculi, and the sac
742
which is the beginning of their route of excretion. It is repre-
sented by the thin tear ducts, which open into the conjuncti-
val sac through the lacrimal points and flow into the lacrimal
sac. From the lacrimal sac, a sort of tank contained in the
homonymous bone fossa, the tears flow into the nasolacrimal
duct that drains the tank, runs in the lateral wall of the nasal
cavities and ends into the inferior nasal meatus.
The superior and inferior lacrimal ducts arise from orifices
known as lacrimal puncta, circular or oval, crater-shaped, open
on the conjunctival sac and situated at the apex of the lacrimal
papillae. These are small pads that protrude on the free margin
of the eyelids in their medial portion, on the border between the
ciliary and the lacrimal part. The upper punctum is much nar-
rower than the lower (0.20–0.25 mm versus 0.30 mm) and is
about 6 mm from the medial angle of the eye; the lower one is
a bit more lateral, at 6.5 mm, so that, with eyelids closed, the
two puncta do not overlap, but are placed next to one another.
Excavated in a dense connective tissue, a dependence of that of
the tarsus, the two lacrimal puncta are constantly open. The
lacrimal ducts, which follow the lacrimal puncta, flow in the
ciliary part of the free margin of its own eyelid until the lacri-
mal sac. Each duct consists of a first portion (shorter) directed
almost vertically (vertical part) and a second portion (longer;
horizontal part) that makes angle with the previous and is
directed medially. The two conduits can lead into the lacrimal
sac independently or, more frequently, by means of a common
trait, more or less developed. The length of the lacrimal ducts
ranges between 8 and 10 mm, and their size is not uniform,
varying in the different portions between 0.3 and 0.8 mm. Due
to the thinness of the walls and the layers that separate them
from the integument, the lacrimal ducts are visible through the
thin skin of the eyelid margin, if a colored liquid is inserted in
their cavities. The tears penetrate the lacrimal ducts by capil-
lary action and the dilatation that the orbicular muscle of the
eye exercises on the sac with suction effect.
The lacrimal sac is a membranous reservoir, of cylindrical
shape, contained in the lacrimal fossa that terminates upward
in a closed end with the fornix, and at the bottom it continues
directly, without precise limits, into the nasolacrimal duct; it
receives laterally the end of the lacrimal ducts that bring the
tears. It is 12–15 mm long and is flattened laterally. If empty
or almost empty, its lumen takes the shape of a sagittal slit,
which measures no more than 3 mm. Normally its capacity is
of 2 ml but, being extensible, it can reach 12 ml. The sac is
contained in a closed cavity, formed by the lacrimal fossa
(composed by the lacrimal bone anteriorly and posteriorly by
the frontal process of the maxilla) and by a fibrous membrane
in continuation of the periosteum, stretched between the ante-
rior and posterior lacrimal crests. It is covered internally by
mucus membrane, lined by a very thin epithelium and its own
integument is infiltrated by numerous lymphoid cells, which
often accumulate in real lymph nodes.
The nasolacrimal duct is a membranous duct which fol-
lows the lacrimal sac and runs in the lateral wall of the nasal
P. Persichetti et al.
fossae, contained in the bony nasolacrimal canal formed by
the lacrimal bone, the maxilla, and the lacrimal process of
the lower turbinate. It flows into the inferior meatus of the
nasal cavities. Due to the turgidity of the cavernous tissue
surrounding it, its cavity may be reduced to a mere slit. The
duct, in fact, is solidly joined to the periosteum of the chan-
nel by a layer of dense connective tissue, rich in elastic fibers,
in which is located a venous plexus, in continuation with the
erectile tissue of the lower turbinate. It is lined internally
with mucous membrane.
8 Vascularization
8.1 Arteries
The ophthalmic artery arises from the internal carotid artery at
the level of the anterior clinoid process of the sphenoid and
penetrates into the optical canal together with the optic nerve.
Within the orbit it leads forward and medially, surrounding the
optic nerve and passing below the superior oblique muscle to
reach the inner corner of the orbit where near the medial palpe-
bral ligament, it divides into its terminal branches. In its course
the artery is accompanied by superior ophthalmic nerve.
Its collateral branches are as follows:
• The central retinal artery, which penetrates inside the
optic nerve at about 15 mm from the eyeball passing
through it until the optic papilla where it divides into an
ascending branch and a descending branch, which in turn
split into medial and lateral branches.
• The lacrimal artery that runs with the lacrimal nerve on
the upper edge of the lateral rectus muscle and is distrib-
uted to the lacrimal gland, provides 1 or 2 zygomatic
branches that supply the temporal fossa and ends with the
lateral palpebral arteries which, passing through each
eyelid in medial direction, anastomose with the medial
palpebral arteries to form the palpebral vascular arcades.
• The ciliary arteries, divided into long posterior and short
ones: they arise from the portion of the ophthalmic artery
that runs beneath the optic nerve, to supply the eyeball
(choroid and the arterial blood supply of the iris); and
anterior arteries: they arise from the muscular branches of
the ophthalmic artery and reach the anterior surface of the
bulb accompanying the tendons of the rectus muscles,
providing episcleral branches and participating in making
the great arterial blood supply of the iris.
• The supraorbital artery, which runs between the superior
rectus muscle and the superior palpebral levator in the
vault of the orbit. Together with the supraorbital nerve, it
passes through the foramen or the supraorbital groove to
supply the frontal region.
• The ethmoidal arteries: the posterior artery, smaller,
passes through the posterior ethmoidal foramen and
Anatomy of the Orbitopalpebral Region 743

supplies the posterior ethmoidal cells; and the anterior

artery, that accompanies the anterior ethmoidal nerve into
the ethmoidal canal and supplies the anterior and middle
ethmoidal cells and the frontal sinus. The anterior eth-
moidal artery enters the cranium through the anterior eth-
moidal canal giving off a meningeal branch to the dura
mater, and nasal branches that descend through the lamina
cribrosa into the nasal cavities.

The terminal branches of the ophthalmic artery are as

follows:

• The superior and inferior medial palpebral arteries that

supply the upper and lower eyelid; they flow behind the
lacrimal sac and reach the respective eyelid where, mov-
ing laterally, anastomose with the corresponding lateral
palpebral artery, branch of the lacrimal artery, forming the
two superior and inferior tarsal arches in correspondence
of the free margin of eyelids. In each eyelid an internal
vascular arch and a peripheral one can be distinguished,
anastomosed with one another, formed by the anasto-
motic confluence between their medial and lateral palpe-
bral arteries. The two medial palpebral arteries are divided
Fig. 14 Arterial and venous vascularization of the eyelids
into superior and inferior: the inferior palpebral artery
comes off the superior one and passes deeply compared to
medial palpebral ligament and the lacrimal canaliculi facial and zygomatic branches), and infraorbital to complete
before reaching the lower eyelid; the superior palpebral the blood supply of the palpebral district (Fig. 15)
artery forms the internal arcade flowing on the anterior
side of the tarsus, below the orbicular muscle at about
3 mm from the free edge. It is often accompanied by a
second arcade, located on the anterior surface of the 8.2 Veins
Muller’s muscle just above the superior tarsal margin,
with which it anastomoses (Fig. 14). Laterally it enters The veins that drain the blood from the eyeball and the
into a relationship with the superior orbital branch of the organs contained in the orbital cavity are as follows:
superficial temporal artery, from which derives the second
main arcade (or peripheral) that is joined medially with • The superior ophthalmic vein whose caliber is remark-
the supraorbital artery. In the lower eyelid just the internal able and is the most important. Its course, in the superior
arch is constant, while the peripheral one, branch of the part of the orbital cavity, corresponds to that of the oph-
suborbital, is sometimes absent. The internal arcade thalmic artery. It begins at the inner angle of the eye with
passes over the tarsus at 2.5 mm from the free margin and two roots from the supraorbital vein and the nasofrontal
is directly associated with the vascular network of the vein through which the vein is anastomosed with the
upper eyelid and the transverse facial artery. angular vein, initial trunk of the anterior facial vein. It
• The frontal artery or supratrochlear leaves the orbit moves backward along the angle between the superior
through the superomedial angle and ascends in the fore- and medial walls of the orbit, comes out through the supe-
head supplying the integument, muscles, and pericranium. rior orbital fissure and reaches the extreme anterior part of
• The dorsal nasal artery that emerges from the orbit the cavernous sinus. It receives the anterior and posterior
between the trochlea of the superior oblique muscle ethmoidal veins, the lacrimal vein, muscles veins, and
and the medial palpebral ligament; it provides branches superior vorticose veins from the eyeball. It has no valves.
to the lacrimal sac and the lateral surface of the nose • The inferior ophthalmic vein, smaller, arises from venules
anastomosing with the lateral nasal artery, the terminal of the lacrimal sac and from the lower eyelid. It runs in the
branch of the facial artery. inferior wall of the orbit and ends, also through the superior
• The external carotid artery contributes by mean of branches orbital fissure, in the cavernous sinus. It is anastomosed
of the arteries: facial (angular artery which anastomoses with with the superior ophthalmic vein. It receives muscle veins
the dorsal nasal artery), superficial temporal (transverse and the inferior vorticose veins. It has no valves.
744
Fig. 15 Arterial vascularization of the upper eyelid with the internal
arcade on the anterior surface of the tarsus and the second arcade,
located on the anterior surface of the Muller’s muscle
• The central retinal vein also drains into the cavernous sinus
and sometimes into the superior ophthalmic vein. At the
palpebral level, in particular, the veins form two networks:
a subcutaneous network that is drained by the superficial
temporal, facial and ophthalmic veins, and a deep network
which is tributary in the two eyelids of the inferior and
superior ophthalmic vein respectively (Fig. 15).
8.3 Innervations
The nerves contained in the orbit are very numerous and of
different physiological value. There is the optic nerve, the
second of twelve paired cranial nerves; the three motor
nerves, the oculomotor, the abducens, the trochlear; the oph-
thalmic nerve, nerve of the general sensitivity; finally a little
nervous ganglion, the ciliary ganglion, with its branches.
The optic nerve consists of many nerve fibers from the
multipolar retinal cells. The nerve is about 50 mm long.
Based on the main connections contracted along its course, it
can be divided into the following four parts:
• The intra-bulbar portion consisted of unmyelinated fibers
that are collected into fascicles that pass through an ori-
fice of the choroidal and pervade the mesh of the lamina
cribrosa of the sclera. When passing through the sclera,
the fibers acquire a myelin sheath, so that the nerve almost
P. Persichetti et al.
redoubles its diameter. Emerging from the eyeball, the
optic nerve is wrapped by three sheaths (dura, arachnoid,
and pia mater) that, at the level of the optic foramen, con-
tinue with the corresponding meninges.
• The orbital portion, approximately 3 cm long, has flexu-
ous course, with a medial convexity in the first curve and
a lateral convexity in the second curve. These curves
invalidate the fact that the nerve is stretched as a result of
movements of the eyeball. This portion is surrounded by
fatty tissue of the orbit and has connections laterally with
the ciliary ganglion in the anterior portion (at the level of
the first 7 mm), 3 mm further back the central retinal ves-
sels penetrate in the optic nerve with a right angle and,
remaining in its thickness, run forward to their emergence
that takes place in the optic disc.
• The canalicular portion is about 8 mm long. In this sec-
tion the nerve passes through the optic canal so having
connections with the roots of the lesser wing of the sphe-
noid bone to which it is securely fastened by expansion of
the dura mater; in the same portion it is related to the oph-
thalmic artery that passes below and laterally.
• The intracranial portion is about 10 mm long. The nerve
reaches the optic chiasm in front of the sella turcica. In
this section it loses the dural layer and is surrounded only
by the arachnoid and the pia mater.
The ophthalmic nerve, the first branch of the trigeminal
nerve – the fifth cranial nerve, is a somatic sensory nerve that
supplies branches to the skin of the forehead and of the cra-
nial vault, to the eye and the attached formations and the
mucous membrane. In the path of the ophthalmic nerve there
is the ciliary ganglion, inserted station on the way of the
parasympathetic fibers that lead to the intrinsic muscles of
the eyeball.
The ophthalmic nerve arises from the internal and ante-
rior part of the semilunar ganglion, exits the Meckel’s cave,
and engages in the thickness of the lateral wall of the cavern-
ous sinus running across it obliquely from below upwards
crossing the oculomotor common nerve. Before reaching the
superior orbital fissure it divides into its three terminal
branches: nasociliary, frontal, and lacrimal. Before entering
the wall of the cavernous sinus the ophthalmic nerve gives
rise to the recurrent meningeal nerve (of Arnold) that is sup-
ply the dura mater that defines the cavernous sinus and forms
the tentorium cerebelli. The ophthalmic nerve also receives
anastomosis from the cavernous plexus of the sympathetic
nervous system and gives anastomotic branches to the troch-
lear and oculomotor nerves.
• The nasociliary nerve is the medial branch of the division
of the ophthalmic nerve. It enters the orbit through the
annulus of Zinn and continuing in a medial direction, is
placed between the medial rectus and the superior oblique
Anatomy of the Orbitopalpebral Region
muscles where it runs to the base of the orbit. Collateral
branches are the long root of the ciliary ganglion, whose
fibers pass through the ciliary ganglion without interrup-
tion and continue until the eyeball with the short ciliary
branches; long ciliary nerves, which go to the eyeball
where they penetrate with the group of short ciliary
nerves; the posterior ethmoid nerve, which enters the
homonymous canal with the posterior ethmoid artery. The
two terminal branches are the infratrochlear nerve, which
enters the medial contour of the orbit, passing under the
trochlea of the superior oblique muscle, where it ends
with ramifications for lacrimal ducts, the conjunctiva, the
skin of the upper medial eyelid region and the skin of the
nose, and the anterior ethmoidal nerve which deflects in
the anterior ethmoidal canal, through which it reaches the
cranial cavity, above the cribriform plate of the ethmoid;
it provides innervation to the nasal cavity by an internal
nasal and an external nasal branch.
• The frontal nerve is the largest terminal branch of the
ophthalmic nerve. It enters the orbital cavity in the upper
part of the superior orbital fissure, externally with respect
to the annulus of Zinn. On its sides run the trochlear
nerve and the lacrimal nerve. It passes through the vault
of the orbital cavity in direct contact with the periosteum,
above the levator muscle complex of the upper eyelids –
superior rectus muscle. On its anterograde path, it is
divided into three branches: the supratrochlear branch,
which leaves the orbital cavity above the trochlea of the
superior oblique muscle and provides the innervation to
the upper eyelid, the root of the nose and the glabella; the
frontal branch, middle – often with origin from the
supratrochlear branch, which exits from the orbit sur-
rounding the orbital margin of the frontal bone, provid-
ing the innervation to the skin of the forehead, the
conjunctiva, and the eyelid; the supraorbital branch,
which is the most lateral, exits from the orbit passing
with the supraorbital artery through the supraorbital inci-
sion of the frontal bone to provide innervation for the
skin of the forehead and scalp.
• The lacrimal nerve enters the orbital cavity through the
superior orbital fissure outside the tendinous ring, runs in
the external part of the orbital vault near the periosteum to
reach anteriorly the lacrimal gland; it also provides inner-
vation to the conjunctiva and the skin of the lateral part of
the superior eyelid. Before reaching the lacrimal gland, it
receives parasympathetic postganglionic afferents,
through the zygomatic nerve (branch of the maxillary
nerve – the second division of the trigeminal), from the
sphenopalatine ganglion to the gland itself.
• Ciliary ganglion: small organelle (1–2 mm) located in the
adipose body of the orbit, on the external side of the optic
nerve. It is a ganglion of parasympathetic nature where
the pre-ganglion fibers end from the Edinger-Westphal
745
Fig. 16 Innervation of the globe: the optic nerve can’t be appreciate
because it is covered by the lateral rectus muscle, the abducens nerve
highlighted going to innervate the inferior oblique muscle and the cili-
ary ganglion
mesencephalic parasympathetic nucleus; the postgangli-
onic fibers for the sphincter muscle of the pupil and cili-
ary arise from the ganglion. Fibers of orthosympathetic
nature and sensory fibers pass through the ganglion with-
out interruption (Fig. 16).
• Short root of the ciliary ganglion is collateral of the ocu-
lomotor nerve; it consists of the preganglionic parasym-
pathetic fibers.
• Long root of the ciliary ganglion is collateral of the naso-
ciliary nerve, containing sensory fibers for the sclera, the
bulbar conjunctiva, and the cornea with origin in the
semilunar ganglion and passes into the ciliary ganglion
without interruption. It also contains orthosympathetic
postganglionic vasomotor fibers for the dilator muscle of
the pupil from the superior cervical ganglion.
• Orthosympathetic root of ciliary ganglion comes from the
cavernous plexus and contains vasomotor postganglionic
fibers from the superior cervical ganglion.
• The short ciliary nerves go from the ciliary ganglion to
the eyeball, passing through small holes arranged in a ring
around the optic nerve.
For the innervation of the extrinsic muscles of the eyeball
remember schematically that:
• The common oculomotor nerve (III) innervates the supe-
rior, medial, and inferior rectus muscles, the inferior
oblique, and the levator muscle of the eyelid.
• The trochlear nerve (IV) innervates the superior oblique
muscle.
• The nerve abducens (VI) provides innervation for the lat-
eral rectus muscle.
746
Finally for the innervation of the eyelid region it has to be
pointed out:
• The sensory innervation is given by the frontal branch of
the ophthalmic nerve that goes anteriorly between the
periorbit of the roof and the superior surface of the eleva-
tor, and divides into two branches – the supraorbital
nerve, which exits from the orbit through the supraorbital
notch (closed as a bridge by the orbital septum) and pro-
vides sensory innervation to the upper eyelid and the fore-
head; and the supratrochlear nerve, which exits from
orbit just laterally compared with bone insertion of the
corrugator supercilii muscle, to be distributed in the
medial region of the upper eyelid and the forehead. The
infratrochlear nerve is given off from the nasociliary
nerve which supplies the skin and conjunctiva of the
medial canthus and the nasolacrimal sac. Finally, there is
the infraorbital nerve which innervates the conjunctiva
and the central skin of the lower eyelid, and the zygomatic-
facial nerve which provides innervation to the inferolat-
eral palpebral portion of the lower eyelid; both are
terminal branches of the maxillary nerve.
• The motor innervation is given by the frontal and zygo-
matic branches of the facial nerve (VII cranial nerve)
innervating the orbicularis muscle; by the superior
branch of the oculomotor nerve (cranial nerve III), which
penetrates the levator muscle of the upper lid from the
lower surface at its posterior third; and by the postgangli-
onic sympathetic fibers from the superior cervical gan-
glion, which run along the neck with the internal carotid
artery, and pass into the skull inside the cavernous sinus to
the superior orbital fissure to innervate the Muller’s mus-
cle. The exact pattern of distribution of these fibers in the
orbit is not completely known, but it seems that they pass
through the orbital cavity with the motor fibers of the
extrinsic muscles of the eyeball.
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(2008) Medial horn supporting ligament in Asian upper eyelids.
Orbit 27:91–96
12. Kakizaki H, Zako M, Nakano T, Iwaki M, Mito H (2004) Anatomical
study of the lower-positioned transverse ligament. Br J Plast Surg
57:370–372
13. Knize DM (2002) The superficial lateral canthal tendon: anatomic
study and clinical application to lateral canthopexy. Plast Reconstr
Surg 109(3):1149–1157
14. Lukas JR, Priglinger S, Denk M, Mayr R (1996) Two fibromuscular
transverse ligaments related to the levator palpebrae superioris:
Whitnall’s ligament and an intermuscular transverse ligament. Anat
Rec 246:415–422
15. May JW, Fearon J, Zingarelli P (1990) Retro-orbicularis oculi fat
(ROOF) resection in aesthetic blepharoplasty: a 6-year study in 63
patients. Plast Reconstr Surg 86:682–689
16. Persichetti P, Di Lella F, Delfino S, Scuderi N (2004) Adipose com-
partments of the upper eyelid: anatomy applied to blepharoplasty.
Plast Reconstr Surg 113(1):373–378
17. Reid RR, Said HK, Yu M, Haines GK 3rd, Few JW (2006)
Revisiting upper eyelid anatomy: introduction of the septal exten-
sion. Plast Reconstr Surg 117:65–66
18. Scuderi G (1975) Chirurgia plastica della regione orbitarla. Minerva
Medica, Torino, Italy
19. Sobotta J, Becher H (1957) Atlas der deskriptive Anatomie des
Menschen. Urban & Schwaerzenberg, Munich, bd 3, pp 296–304
20. Spiegel JH, DeRosa J (2005) The anatomical relationship between the
orbicularis oculi muscle and the levator labii superioris and zygomati-
cus muscle complexes. Plast Reconstr Surg 116(6):1937–1942
21. Yuzuriha S, Matsuo K, Kushima H (2000) An anatomical structure
which results in puffiness of the upper eyelid and a narrow palpe-
bral fissure in the Mongoloid eye. Br J Plast Surg 53:466–472
 Upper Eyelid Blepharoplasty

Bryant A. Toth and Stephen P. Daane

“Gather a fold of lid skin between a couple of fingers, or rise it up with a hook, and lay the fold between two
small wooden bars. Bind their ends very tight. The skin, deprived of nutrient, dies in about ten days and the
enclosed skin falls off, leaving no scar.”
TADHKIRAT OF ALI IBN ISA OF BAGHDAD, AD 940–1010

1 Introduction A male patient typically has different expectations from

According to the American Society of Plastic Surgery sur-
veys, upper eyelid blepharoplasty yields the highest satis-
faction rate of any plastic surgery procedure. The
attractiveness of this procedure is the short length of the
operation, the ability to perform the operation under local
anesthesia, the relatively brief recovery time (time away
from work), and inconspicuous scarring due to the location
of the incisions.
2 Differences Between the Male
and Female
The difference between the male and the female eyelid is a
direct result of the difference in bony facial contour. The
male supraorbital rim is lower and more prominent and has a
greater midline depression (Fig. 1); the eyebrows rest lower
and have a horizontal contour as compared with the charac-
teristic high arching eyebrow of the female. There is a
smaller vertical distance between the eyebrow and the eye-
lashes in the male. In the female the average tarsal crease
corresponding to the levator insertion is positioned 6–8 mm
above the lash line, the male frequently has a lower tarsal
crease with a fold of skin covering the crease [3].
esthetic eyelid surgery than a female. In men, the chief con-
cern is usually the desire to eliminate a tired or angry appear-
ance; women desire visible skin below the eyelid crease to
provide a platform for the application of make-up. The issues
of concern are not simply a result of advancing age; heredi-
tary characteristics are often a dominant influence on perior-
bital contours. The surgical technique for blepharoplasty in
both men and women must be designed to achieve the desired
postoperative appearance and contours. The modifications
are more than superficial. An undesirable “surgical look”
will be created if the eyelid crease is set too high or if the
eyelash to eyebrow distance is altered, if lateral upper eyelid
hooding is not corrected or if the shape and position of the
lateral canthus is altered. Ethnic characteristics, such as the
lower upper eyelid crease in Asians, may be modified, but
should not be eliminated.

B.A. Toth, MD, FACS (*)

Private Practice, Toth Plastic Surgery, San Francisco,
CA, USA
Clinical Professor of Surgery, University of California,
San Francisco, CA, USA
e-mail: tothbryant@gmail.com
S.P. Daane, MD
Private Practice, San Francisco and San Ramon, CA, USA Fig. 1 Bony differences in the male bony anatomy

© Springer Berlin Heidelberg 2016 747

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_52
748
3 Preoperative Evaluation
and Consultation
The preoperative evaluation must be thorough, including
obtaining a history of dry eye symptoms and performing a
Schirmer’s test. The preoperative evaluation must include a
thorough ophthalmic evaluation so that preexisting abnor-
malities, including visual acuity, can be documented and
conditions that may influence the surgical result may be
evaluated. If the surgeon does not have this ability, the eval-
uation should be performed by an ophthalmologist.
If significant eyebrow ptosis is present in the lateral
third of the brow, especially in elderly patients with visual
field obstruction, consideration should be given to per-
forming a limited lateral brow lift via a temporal facelift
incision or pre-hairline incision. The upper eyelid blepha-
roplasty must not excise so much skin that eyelid closure
is inhibited, or that the eyelash to eyebrow distance is
diminished. There may be increased eyebrow ptosis fol-
lowing upper eyelid blepharoplasty performed without
browlifting. Scars from incisions in the mid-forehead or
directly above the eyebrow are unacceptable in the vast
majority of patients and in our opinion should be avoided
in a cosmetic setting.
Visual field obstruction implies a functional deficit and
corrective surgery can be considered reconstructive rather
than cosmetic. For example, an elevated tarsal crease is a
sign of levator dysfunction. This distinction has possible
financial implications for insurance reimbursement. The
presence of preoperative asymmetry or previous surgical
changes must be determined. Preoperative photographs
should be used as an intra-operative guide, as a tool for com-
paring before and after, and for medical-legal documenta-
tion. Thyroid disease and bleeding disorders should be
identified preoperatively, including a history of cigarette
smoking or the use of aspirin, aspirin-containing products, or
other platelet inhibitors such as dietary herbs.
The preoperative discussion and consultation should
clearly delineate realistic expectations and the limitations of
surgery. The limitations of performing blepharoplasty with-
out eyebrow elevation should be defined and the compro-
mises involved in eyebrow surgery should be clearly
explained. In cases of extreme lateral brow ptosis, blepharo-
plasty alone may result in an unnatural appearance with a
greatly diminished brow to eyelid distance. The patient
should understand the surgical implications of removal of
redundant skin and orbital fat. The patient should also under-
stand the inability to improve skin texture or color, or to sig-
nificantly alter the rhytids referred to as “laugh lines” or
“crow’s feet” without an aggressive skin excision lateral to
the orbital rim.
B.A. Toth and S.P. Daane
4 Surgical Technique and Pearls
In the vast majority of patients, the preferred anesthesia for
upper and lower eyelid blepharoplasty is local infiltration of
anesthetic combined with intravenous sedation. Even when
general anesthesia is used, local infiltration is necessary due
of the hemostatic effect of epinephrine and the postoperative
analgesia. The addition of sodium bicarbonate to the local
infiltration (1:10 mixture), in an awake patient, decreases the
discomfort of the local injection. However, with adequate
intravenous sedation, the discomfort associated with local
infiltration is of less concern. The use of intravenous seda-
tion requires adequate patient monitoring. Helpful tech-
niques for local infiltration include very slow injection
through a 27 or 30 gauge needle and the use of postinjection
digital pressure to aid hemostasis and decrease postoperative
ecchymosis.
The skin incisions must be marked precisely and sym-
metrically with the patient in a sitting position. The markings
are placed prior to injections of local anesthesia to eliminate
error from the induced tissue distortion. The upper eyelid
incision in a man should be marked so that the crease is rela-
tively low, generally not more than 8 mm from the eyelash
line. The upper portion of the excision should not extend
onto the thicker eyebrow skin and should remain at least
10 mm from the inferior cilia of the eyebrow. If this guide-
line is disregarded, the surgery may severely reduce the
eyebrow-to-eyelash distance. This produces an undesirable
appearance with a significant risk of inhibiting eyelid closure
(lagophthalmos) [1, 2].
The upper eyelid incision should not extend medially
onto the nose, or an epicanthal fold may result. Excessively
redundant skin medially can be removed by extending the
incision upward, but not further nasally. In patients with pro-
nounced redundant tissue, it may be necessary to extend the
incision further laterally. The lateral upper eyelid incision
must be planned so that it will leave at least a 5 mm skin
bridge above a lateral lower eyelid incision. Efforts should
be made to leave this incision in a natural skin crease (Fig. 2).
Redundant orbital fat in the upper eyelid is most often
found in the medial pocket (Fig. 3) and is excised utilizing
the cautery (Fig. 4); access to the medial and central orbital
fat pads is via sharp dissection through the orbicularis oculi
and orbital septum with curved Stevens scissors. Laterally,
although partial excision of the lacrimal gland has been
advocated by some, we strongly feel it should be avoided.
Since the lacrimal gland receives its innervation through the
orbital lobe, excision of this portion of the lacrimal gland
may leave the remainder of the gland denervated and dys-
functional. When necessary, a prolapsed lacrimal gland can
be reduced by resuspending the gland to the periosteum of
Upper Eyelid Blepharoplasty
Fig. 2 Patient markings
Fig. 3 (a, b) Normal anatomy
a b
of the upper eyelid
Fig. 4 Medial fat
the lacrimal fossa with a nonabsorbable suture. Subcutaneous
fat and redundant tissue which has descended from the eye-
brow, including ROOF fat (retro-orbicularis oculi fat), should
be excised when necessary to obtain satisfactory and sym-
metrical contour.
The adjunctive technique of internal browpexy has a lim-
ited role in blepharoplasty. The procedure stabilizes the eye-
brow by securing the subcutaneous eyebrow tissues to the
underlying periosteum. This must be considered effective
only for minimizing or eliminating a post-blepharoplasty
drop in eyebrow position; it cannot be expected to effectively
raise the eyebrow. Moreover, due to the position of the supra-
orbital and supratrochlear neurovascular bundles, this proce-
dure is only applicable to the central and lateral eyebrow.
749
We routinely remove a strip of preseptal orbicularis oculi
in order to create a crisp tarsal fold. It is extremely helpful to
redrape the skin and excise additional redundant skin prior to
closing the skin incision for upper eyelid blepharoplasty
(Fig. 5). This is important, regardless of how carefully and
precisely the preoperative markings are placed. Most often,
additional tissue is resected laterally. This will preclude a
postoperative lateral hooding which characterizes the “surgi-
cal look.”
In men, the use of sutures to stabilize the upper eyelid
may be of benefit. Sutures allow precise symmetrical crease
positioning and eliminate the possibility of upward or down-
ward migration of the pretarsal orbicularis and skin. The
crease can be softened by placing the sutures from the deeper
750
Fig. 5 Intraoperative adjust-
ment of markings
Fig. 6 A 40 year-old woman pre- and postoperative from upper and lower eyelid surgery
portion of the orbicularis to the superficial portion of the
levator aponeurosis.
When eyelid ptosis is identified preoperatively, it can be
addressed during the same procedure with plication of the
levator aponeurosis. Careful preoperative measurements
are necessary to gauge the amount of levator plication, as
lidocaine blocks Mueller’s muscle function intraopera-
tively and Herring’s law dictates that the unaffected contra-
lateral upper lid will droop following levator plication. This
B.A. Toth and S.P. Daane
procedure is best done with the patient awake so that the
new levator position can be verified prior to definitive
suture and closure.
Figure 6 shows the pre- and postoperative results of a 40
year-old woman who underwent blepharoplasty, upper and
lower.
Figure 7 shows a 65 year-old man with both blepharocha-
lasis and brow ptosis who underwent upper eyelid blepharo-
plasty without browlifting.
Upper Eyelid Blepharoplasty
Fig. 7 A 65 year-old patient, before and after
5 Complications of Upper Eyelid
Blepharoplasty
Fortunately, complications from blepharoplasty are very
rare but can be disastrous. The essence of an elective cos-
metic procedure implies that complications are poorly
accepted. Proper preoperative evaluation and planning with
meticulous surgical technique will greatly reduce the risk of
complications.
Postoperative complications are covered in a separate
chapter, but the majority of postoperative abnormalities
include eyelid malposition or asymmetry, usually corrected
751
with a secondary procedure. This is often due to too much,
not enough, or asymmetrical excision of skin or fat.
Postoperative eyelid malposition may include upper eyelid
retraction or ptosis. The latter is most often caused by
attempting to resect the medial and central orbital fat pads by
entering the orbital septum too low resulting in injury to the
levator aponeurosis. Dry eye symptoms due to lagopthalmos
or lacrimal injury are treated with topical ocular lubricants in
the form of drops or ointment and with repair of eyelid mal-
position when necessary. The most serious complication
from blepharoplasty is optic nerve injury from retrobulbar
hemorrhage, with an incidence of 1 in 65,000.
752
6 Summary
Goals in upper eyelid blepharoplasty are different in the male and
female, dictated by different expectations and different anatomy.
The low and prominent position of the male eyebrow is the main
anatomical difference. The surgical plan must be designed to
attain the desired result. A browlifting procedure can be consid-
ered when significant eyebrow ptosis is present. Blepharoplasty is
a relatively safe procedure, and the benefits of cosmetic eyelid sur-
gery are predictable and readily evident. Although serious compli-
cations can be devastating, they are extremely rare and the common
complications are usually easily corrected with minor revisions.
B.A. Toth and S.P. Daane
References
1. Rees TD, LaTrenta GS (1994) Chapter 18: Bleparhoplasty–Baggy
eyelids. In: Aesthetic plastic surgery, 2nd edn. WB Saunders,
Philadelphia.
2. Rees TD, LaTrenta GS (1994) Chapter 19: Blepharoplasty–Surgical
procedures. In: Aesthetic plastic surgery, 2nd edn. WB Saunders,
Philadelphia.
3. Spinelli HM (2004) Atlas of aesthetic eyelid and periocular surgery.
Saunders Elsevier, Philadelphia
 Asian Upper Blepharoplasty
Hop Le
1 Introduction
The principle goal of the Asian upper blepharoplasty, or the
“double eyelid” procedure, is to create a crisp, clean upper
eyelid fold thus imparting the appearance of a wider eye. In
order to successfully perform Asian upper blepharoplasty, it
is essential to have a clear understanding of the underlying
anatomy, to be able to appreciate the subtle nature of the
patient’s desire and expectations, and to tailor the procedure
to the patient’s specific features and their aesthetic demands
in the context of their cultural identity. The double eyelid
procedure is the most commonly requested cosmetic proce-
dure by Asian patients [1]. Approximately 50 % of East
Asians have a “single eyelid” characterized by a lack of a
supratarsal fold with the upper lid draping like a single sheet
from the supraorbital ridge to the eyelashes [2]. Even for
those Asians with double eyelids, many desire enhancement
to improve upon a rudimentary or small fold with abundant
periorbital fat and excess eyelid skin.
What have long been aesthetically desirable by Asians are
eyes that convey a youthful and bright appearance without
losing their ethnic identity. This desire does not necessarily
relate directly to Western influences. The term
“Westernization” used to characterize Asian upper blepharo-
plasty is antiquated and misleading. Asians do not necessar-
ily want to look Caucasian. More accurately, Asian patients
desire to enhance the natural beauty of their eyes while
retaining the appearance of their overall ethnic norm [3, 4].
We would like to emphasize that few other aesthetic sur-
gical procedures are as influenced by patient desire and cul-
tural norms as the Asian upper blepharoplasty [5, 6].
Anatomical characteristics and variations among Asian
single upper eyelids and Caucasian double eyelids need to be
clearly understood in order to reliably create a clean crisp
H. Le, MD, FACS
Department of Plastic Surgery, Kaiser Foundation Hospital,
San Rafael, CA, USA
e-mail: hoplemd@gmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_53
fold that is durable over time. Interracial relationships and
population migration has resulted in huge variations and
blending of the appearance of the Asian-Caucasian upper
eyelid. Good examples include the “Happas” of Hawaii,
Filipinos, Eurasians, and Mongolians along the Silk Road
and Middle East border. Many patients in interracial mar-
riages express a desire to have eyes like their children and
not necessarily those of their spouse.
2 Anatomical Considerations
Successful outcomes depend on a detail understanding of the
anatomic differences that characterize the Asian eyelid which
can account for a wide variation when compared to the
Caucasian population. Ethnic characteristics of Asian upper
eyelid include (1) lack of superior palpebral fold, (2) exces-
sive fat especially preseptal and/or septal, (3) laxity of pret-
arsal skin, and (4) epicanthal fold.
Lack of a supratarsal fold is a characteristic feature of
East Asian eyelids. In Asians the skin is tightly bound to the
underlying muscle, but there is a loose areolar tissue between
the pretarsal orbicularis oculi muscle and tarsus allowing the
muscle to smoothly glide over the tarsus with the pretarsal
skin drooping as the eyelid rises. The preseptal fat or sub-
muscular fibroadipose layer is continuous with the eyebrow
fat pad and adds thickness to the upper lid. Even the preapo-
neurotic fat pad, contained by the orbital septum, is more
prominent (Fig. 1) [2, 7].
In Caucasian double eyelids, the fat pad extends inferiorly
onto the upper lid only as an areolar fascial layer along the
posterior aspect of the orbicularis oculi muscle. The septum
fuses with the levator aponeurosis at the superior aspect of
the tarsus, preventing the anterior and inferior migration of
the preaponeurotic fat.
Anatomically, the supratarsal eyelid is defined by that
portion above the crease. Below the crease is the pretarsal
eyelid. As the levator contracts, the supratarsal crease invagi-
nates and the supratarsal eyelid doubles on itself, forming a
753
754
Levator palpebrae m.
Superior rectus m.
Absence of
superior palbrebal
fold
Orbital septum
Levator
aponeurosis
Muller's muscle
Orbicularis
oculi m.
Tarsal plate
Fig. 1 Anatomical section of the Asian eyelid: note the absence of the
supratarsal fold and the prominence of the preaponeurotic fat pad
double-eyelid fold which covers a portion of the pretarsal
eyelid. The portion of the pretarsal eyelid that is still exposed
when the eyelid is open in the primary gaze position is the
pretarsal show or height of the double fold [8, 9].
The palpebral crease is formed by the insertion of the
levator aponeurosis onto the pretarsal skin and orbicularis
oculi muscle (Fig. 2). It has been postulated that the levator
filamentous expansion penetrates the orbital septum and
orbicularis oculi muscle, attaching directly to the skin, thus
creating a superior palpebral crease when the lid opens as the
levator exerts an elevating pull onto the relatively immobile
pretarsal skin invaginating the unified pretarsal unit under
the nonadherent and relatively mobile preseptal skin divid-
ing the upper lid into two segments [10]. It is debatable
whether the levator filaments themselves reach the skin or
whether these filaments attach to fibrous septae that connect
to the pretarsal skin, orbicularis oculi muscle, and tarsus.
Anatomic studies have found no evidence of direct attach-
ment between the levator filaments and the dermis [11].
Instead, the aponeurotic filaments may course inferiorly
into the pretarsal segment, attaching to fibrous septae that
extend from tarsus to pretarsal skin penetrating the pretarsal
orbicularis oculi muscle. This produces an adherence between
the pretarsal skin, orbicularis oculi muscle, and tarsal plate.
In the Asian single eyelid, the levator filaments do not pen-
etrate the orbital septum and orbicularis oculi muscle, but ter-
minate on the tarsal plate. In this situation, the pretarsal skin is
redundant and no palpebral fold is created upon eyelid open-
ing. Due to the lack of preseptal adhesions, the periorbital fat
H. Le
Post septal fat
Orbital septum
Orbicularis oculi m.
Levator aponeurosis
Superior palpebral fold
Dermal attachment
of levator
aponeurosis
Tarsal plate
Fig. 2 Anatomical section of the Western eyelid: note the presence of
the superior palpebral fold
compartment descends inferiorly, coursing anterior to the tarsal
plate which gives an appearance of puffiness of the single eye-
lid. The lack of supratarsal fixation causes a relaxed redundant
pretarsal skin which covers the tarsal margin. This imparts an
impression of diminished width of the palpebral fissure and
gives a slit-eye appearance and occasionally a suggestion of
ptosis also known as pseudoptosis orientalis [12].
The epicanthal fold may vary widely but is usually small.
The epicanthal fold is present in approximately 40–90 % of
East Asians [13]. If large, this web-like structure blunts the
medial canthus, obscures the lacrimal caruncle, and produces
an impression of diminished width of the palpebral fissure and
diminished intercanthal distance. The epicanthal fold covers
the upper eyelashes and the true upper eyelid margin medially
and gives the appearance of short eyelashes and narrow palpe-
bral fissure. It is usually associated with skin redundancy of
the entire upper lid. The epicanthal fold may be accentuated
with an upper blepharoplasty procedure pulling on the lax epi-
canthal skin laterally creating a sharp skin ridge or webbing
therefore making the eyes appear rounder and eyelid fissures
shorter distracting from the overall aesthetic result.
3 Surgical Techniques and Pearls
The procedure is ideally performed under local anesthesia
with 1 % lidocaine with 1:100,000 epinephrine. The minimal
amount of infiltration is given to make the patient comfortable
Asian Upper Blepharoplasty
without distorting the anatomy. Precise preoperative skin
marking and frequent reassessment with the patient opening
and closing the eyelid will lead to a symmetrical and desired
result. Skin marking should be done with an ultrafine tip
marker after sterile skin prep but before local anesthetic infil-
tration. The eyelid skin should be tensed cephalically so
there is a slight eversion of the eyelash. If marking is per-
formed with the skin lax, the surgical fixation is likely to
result in a palpebral furrow that is higher than planned.
Subtle variations in surgical technique can result in signifi-
cant sculpturing of the upper eyelid. The surgeon needs to be
able to translate patient desires into an operation that reliably
sculptures the upper eyelid to the patient’s general specifica-
tion. Creating an adhesion between the pretarsal dermis-
orbicularis oculi muscle and levator aponeurosis-tarsus can
effectively produce the broad-like pretarsal unit that invagi-
nates beneath the preseptal skin upon levator contraction.
Each procedure needs to be individualized. Preoperatively, it
is critical to consider differences in the level of the palpebral
furrow and depth and variations in size and shape. Attention
to meticulous analysis of existing anatomy includes presence
of existing fold, depth and vertical position of an existing
palpebral crease, degree of lid fullness and fat, prominence
of an epicanthal fold, and any preexisting asymmetry. It is
helpful to use a cotton tip applicator or a bent paper clip to
estimate or create a fold to the patient’s desire and also to
assess the effect of what a fold creation will have on the epi-
canthal fold.
It is imperative to understand the patient’s desires and
expectations. In particular a double eyelid procedure does
not necessarily mean Westernization of the eyelids. Most
patients prefer to maintain their Asian trait while enhancing
its natural beauty. Westernization includes reduction of the
lid fullness and creation of a large, deep-set upper lid by
removing relatively large amounts of skin and fat as well as
effacement of the epicanthal fold. Contemporary Asian
blepharoplasty is characterized by an incision closer to the
ciliary margin, usually 6–8 mm from the lash line with the
skin taut. There is resection of smaller amounts of skin and
fat. The epicanthus is conservatively adjusted. There have
been numerous modifications and variations upon tech-
niques, but essentially there are mainly two general catego-
ries: (1) nonincisional suture technique and (2) incisional
fixation technique which is our preferred technique. The
nonincisional suture technique relies on permanent sutures
to compress and create a scar that results in adhesions [14].
Although the suture may be permanent, the fixation is usu-
ally unstable with considerable relaxation and recurrence is
frequent. To compensate, the supratarsal crease is usually
placed higher on the eyelid in anticipation for relaxation and
relapse. This technique at best may be an option for young
patients who do not have any skin excess and absolutely do
not want an incision.
755
The incisional fixation technique is more reliable and
definitive thus making it our preferred technique for all
patients. Even with this technique there have been numerous
variations on how to best create the supratarsal fold. Most
procedures describe some sort of skin to aponeurosis or tar-
sus fixation based on anatomical studies describing insertion
of the levator aponeurosis to the pretarsal skin. However,
electron microscopy evaluations have not revealed any evi-
dence of levator insertion into the skin itself [11].
Nonetheless, the orbicularis oculi muscle to skin attach-
ment is firm and reliable, thus making a levator aponeurosis
to orbicularis oculi muscle fixation our preferred technique
as described by Park [15]. It is important, however, to clearly
define the levator aponeurosis along with a wedge resection
of overlying fat which serves as a barrier to a well-apposed
adhesion [16]. There should be a minimal of three fixation
points: midpupillary and medial and lateral to the limbus.
Medially, the levator expansion tends to be flimsy and fixa-
tion is usually weakest incorporating mainly septum and
levator fibers. Fixation is usually the strongest laterally as the
levator aponeurosis is thickest and well defined. Buried per-
manent 6-0 clear nylon/prolene or long lasting absorbable
6-0 PDS sutures are used for fixation (Fig. 3). The skin inci-
sion is then closed with interrupted or running sutures to
invert the skin edges. Skin sutures should be removed by the
fifth postoperative day.
Essentially, the shape and height of the supratarsal fold
determines the overall aesthetic outcome. Determining and
Buried
non-absorbable
suture
Levator aponeurosis
Superior tarsal border
Dermis
Fig. 3 Creation of the superior palpebral fold with a non-absorbable
suture (B) Suturing to creating an adhesion between the pretarsal
dermis-orbicularis oculi muscle and levator aponeurosis-tarsus
756 H. Le

controlling the height of the superior palpebral fold is based
on two factors: the distance from the ciliary margin and the
amount of preseptal skin that hoods over the surgically cre-
ated palpebral fold. The pretarsal show basically determines
the actual size of the lid. We most commonly place the height
of the superior palpebral fold at approximately 6–8 mm from
the ciliary margin with the skin taut. Rarely, will the fold be
placed at a height greater than 10 mm.
The shape of the eyelid can be controlled by the shape of
the inferior incision. An almond shaped eyelid is created
when the incision is made so that it is parallel to the ciliary
margin from the medial to lateral limbus. A more round eye-
lid shape results from placing the lateral aspect of the inci-
sion slightly inferior at the level of the lateral canthus than at
the level of the lateral limbus [17]. Many women prefer an
almond eye shape with a lateral flare where the fold is slightly
higher laterally (Figs. 4, 5, and 6).
Up to 90 % of Asians have an epicanthus. The epicanthus
should be addressed on an as needed basis. If preoperative
testing by tenting the upper lid skin magnifies the epicanthal

Fig. 4 Operative steps in an Asian upper blepharoplasty. Steps for successful Asian upper blepharoplasty: (a) Preop photo (b) Intraoperative steps:
1. Typical single layer eyelid. 2. Estimation of fold with forceps. 3. Lid skin marking. 4. Measuring height of skin incision. 5. Marking is 6 mm
from ciliary margin. 6. Skin incision. 7. Undermining of upper lid skin flap. 8. Exposure of septum and underlying fat and levator aponeurosis.
9. Hatch markings for suture placement. 10. Dermomusculo- aponeurotic suture placement. 11. Immediate supratarsal fold creation
Asian Upper Blepharoplasty
Fig. 4 (continued)
b
Fig. 5 Preoperative and postoperative result in a young patient
fold and distracts from the overall aesthetic result then an epi-
canthoplasty should be performed. Epicanthoplasty has a his-
tory fraught with undue complexity including incisions in
diverse directions, inability to incorporate the medial canthal
incisions with the rest of the double-lid incision, lack of clear
landmarks and reference points, and prominent scarring.
Many techniques have been described such as the Mustarde’s
four flap along with its modifications, VW plasty, VY advance-
ment, VM plasty, W plasty, and square flap. In our experience,
757
the epicanthal deformity is usually small and only requires a
simple procedure confined to the eyelid [16, 18–20].
The Y-V advancement and Z epicanthoplasty are rela-
tively straightforward and give an adequate correction with-
out significant scarring [21, 22]. With these techniques, the
incision should not extend into the nasal skin; there should
be an anchoring deep suture to the nasal periosteum along
with medial release so that correction can be adequate
enough to expose the caruncle.
4 Complications
Complications are rare but include the same problems that
may arise with any upper blepharoplasty. In particular, the
most common problem is relapse due to lack of solid fixation.
This tends to occur with the non-incision technique or inad-
equate fixation such as skin to septal adhesion. We believe
the most stable fixation occurs between the orbicularis mus-
cle and the clearly defined levator aponeurosis. Another
potential cause of patient dissatisfaction is over
Westernization of the upper eyelid appearance. Again, we
cannot emphasize enough that the majority of Asian patients
do not necessarily want to look Caucasian, but merely seek
to enhance the natural beauty of their Asian eyelids. This is
achieved by creation of a supratarsal fold that reduces the
fatty fullness of the lid and gives the appearance of a wider
almond shaped eye. Dissatisfaction is more often associated
with a supratarsal fold that is too high rather than too low.
Most of our supratarsal folds are placed at 6–8 mm from the
758
Fig. 6 Preoperative and postoperative result in a middle-aged patient
ciliary margin. There should be minimal to no skin excision
to allow for sufficient preseptal skin remaining to drape over
the crease, thus hiding the incision and determining the
desired amount of lid show. Too much skin excision will
result in lid crease that is too high and possible eversion of
the lashes with unsightly red mucosal tarsal show [23, 24].
Although a strong bite of levator aponeurosis is desired
for a firm fixation, care must be taken to not have full thick-
ness penetration that may result in injury to the globe. The
fixation suture should firmly approximate the tissue but not
strangulate it.
Patients should be counseled that swelling may last 1–2
weeks at which time the upper lid crease may appear higher
then intended and overcorrected. As the swelling subsides
the supratarsal skin will relax and drape over the incision
enhancing the appearance of the crease and setting the
amount of pretarsal show. Icing, NSAID avoidance, and con-
trol of hypertension are routine for the postoperative course.
5 Summary
The goal of the “double eyelid” procedure is to create a small
palpebral fold along with reduction of eyelid fullness to
make the eye look slightly larger and give the appearance of
youthfulness, alertness, and vitality without compromise of
ethnic identity. Many of the techniques learned from Asian
H. Le
blepharoplasty may also be applied to Caucasian blepharo-
plasty to afford a clean, crisp, well-defined upper lid fold, but
not necessarily vice versa. Although a very commonly
performed procedure that appears quite simple technically,
the Asian upper blepharoplasty can be fraught with
dissatisfaction. In order to successfully perform Asian upper
blepharoplasty it is important to have a clear understanding
of the patient’s desire and expectation, cultural norms and
identity, underlying anatomical differences, and a reliable
and durable surgical technique.
This is a procedure where differences in millimeters can
have a huge impact on the desired outcome. It is a procedure
that requires meticulous attention to detail and clearly exem-
plifies the artistic finesse in combination with clear under-
standing of the anatomy and technical expertise of the plastic
surgeon. Clearly Asian blepharoplasty is the window into the
world of Asian aesthetics.
References
1. Ohmori K (1990) Aesthetic surgery in the Asian patient. In:
McCarthy JG (ed) Plastic surgery, vol 3. Saunders, Philadelphia,
pp 2420–2426
2. Liu D, Hsu WM (1986) Oriental eyelids: anatomic difference and
surgical consideration. Opthal Plast Reconstr Surg 2:59–64
3. Matsunaga RS (1985) Westernization of the Asian eyelid. Arch
Otolaryngol 111:149–153
4. Sayoc BT (1974) Surgery of the oriental eyelid. Clin Plast Surg
1(1):157–170
5. Flowers RS (1987) The art of eyelid and orbital aesthetics: multira-
cial surgical considerations. Clin Plast Surg 14:703–721
6. Park JS, Ham KS et al (1990) Study on the beauty sense for the eyes
in Korean. Korean J Plast Surg 17:196
7. Sayoc BT (1956) Absence of superior palpebral fold in slit eyes: an
anatomic and physiological explanation. Am J Ophthalmol 42(2):
298–300
8. Sayoc BT (1967) Anatomic considerations in the plastic construc-
tion of a palpebral fold in the full upper eyelid. Am J Ophthalmol
63:155–158
9. Siegel R (1984) Surgical anatomy of the upper eyelid fascia. Ann
Plast Surg 13(4):263–723
10. Collin JR, Beard C, Wood I (1978) Experimental and clinical data
on the insertion of the levator palpebra suprioris muscle. Am J
Ophthalmol 85:742–801
11. Morikawa K, Yamamoto H, Uchinuma E et al (2001) Scanning
electron microscopic study on double and single eyelids in
Orientals. Aesthetic Plast Surg 25(1):20–24
12. Uchida J (1962) A surgical procedure for blepharoptosis vera and
pseudoblepharoptosis orientalis. Br J Plast Surg 15:271
13. Lee SI (1985) A statistical study of upper eyelids of Korean young
women. Korean J Plast Reconstr Surg 12:325
14. Baek SM, Kim SS et al (1989) Oriental blepharoplasty: single-
stitch, nonincision technique. Plast Reconstr Surg 83:236
15. Park JI, Park MS (2007) Double-eyelid operation: orbicularis oculi-
levator aponeurosis fixation technique. Facial Plast Surg Clin North
Am 4:315–326
16. Yoon KC, Park S (2009) Systematic approach and selective tissue
removal in blepharoplasty for young Asians. Plast Reconstr Surg
102(2):502–508
Asian Upper Blepharoplasty
17. McCurdy JA Jr (2005) Upper blepharoplasty in the Asian patient: the
“double eyelid” operation. Facial Plast Surg Clin North Am
13:47–64
18. Yoon K (1993) Modification of Mustarde technique for correction
of epicanthus in Asian patients. Plast Reconstr Surg 92:1182–1186
19. Lin SD (2000) Correction of the epicanthal fold using the
VM-plasty. Br J Plast Surg 53:95–99
20. Mulliken JB, Hoopes JE (1975) W-epicanthoplasty. Plast Reconstr
Surg 55:435–438
759
21. Li FC, Ma LH (2008) Double eyelid blepharoplasty incorporating
epicanthoplasty using Y-V advancement procedure. J Plast Reconstr
Aesth Surg 61:901–905
22. Park JI (2000) Modified z-epicanthoplasty in the Asian eyelid. Arch
Facial Plast Surg 2(1):43–47
23. Song IC, Hunter JG, Chung SC (1991) Problems in the management
of blepharoplasty in Orientals. Probl Plast Reconstr Surg 1:542
24. Hin LC (1985) Unfavorable results in oriental blepharoplasty. Ann
Plast Surg 14:523–534
 Lower Eyelid Blepharoplasty
Kristin A. Boehm and Foad Nahai
1 Introduction
Surgery is a discipline grounded in precision and exactitude.
Surgeons must possess technical skill, anatomic knowledge,
and an ability to improvise when intraoperative situations
change or prove different than anticipated. There are how-
ever some operative procedures that have more narrow mar-
gins for error than others, where the difference of a millimeter
in positioning or scar formation can dramatically affect out-
come. Surgery of the lower eyelid falls into this category.
The periorbita is unquestionably a focal feature of the
face. Its nuances and subtleties convey individuality as well
as emotional expression. The eyes are a most important and
often initial means of nonverbal communication. Naturally
then, there is a tendency to want to preserve this structure
despite inevitable changes that occur with the aging process.
Such is the motivation behind the lower lid blepharoplasty
being one of the most common surgical procedures in both
men and women. While the lid region may be relatively
small in terms of area, it is one of anatomic complexities.
Understanding the intricacies of this area is crucial to the
safe performance of blepharoplasty and achieving youthful,
natural results that can be maintained for years postopera-
tively. Accurate assessment of the changes that occur with
aging and familiarity with the techniques to correct these can
restore youthfulness to the lower lid and minimize those
complications which can have both aesthetic and functional
consequences.
The youthful lower eyelid is a smooth, convex structure
extending from the lid margin to the midface region. The
lower lid is taut as it abuts the globe at a level just above the
inferior limbus. The lateral canthal angle sits approximately
2 mm higher than the medial canthal angle, thereby
creating an upward or positive canthal tilt. With aging,
K.A. Boehm, MD • F. Nahai, MD (*)
Private Practice, Paces Plastic Surgery, Atlanta, GA, USA
e-mail: nahaimd@aol.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_54
tarsoligamentous laxity and skin excess appear, and the eye
assumes a more rounded appearance with a negative canthal
tilt to the subciliary margin. Volume deflation and skin atten-
uation confer a hollow or concave contour. Herniation of the
infraorbital fat pads becomes prominent and the demarcation
between the lower lid and cheek becomes a well-defined
structure at the level of the infraorbital rim (Fig. 1). A com-
prehensive lower lid blepharoplasty technique must there-
fore strive to correct all of these aging changes in an effort to
restore a youthful and unoperated appearing periorbita.
Success in lower lid blepharoplasty surgery relies on the
ability to recognize the specific changes in an individual
patient, appreciate the anatomic basis for these changes and
employ techniques that work to counteract these changes.
2 Anatomy
Viewed externally, the lower lid is perhaps better described
as an area rather than a specific structure, one which includes
the lid margin, cheek, and midface regions. The lower eyelid
is ideally positioned just slightly above the inferior limbus
without any visible scleral show. Approximately 5 mm below
the lid margin is the lower lid crease formed by the lower lid
retractors inserting into the dermis. The lower lid tends to
slope upward as it moves from medial canthus to lateral can-
thus conferring what is known as a positive canthal tilt. The
tear trough represents the transition between the orbicularis
muscle and thin skin of the eyelid to the malar fat and thicker
skin of the upper cheek [1].
The lower eyelid is separated into an anterior and poste-
rior lamella. Skin and orbicularis muscle compromise the
anterior lamella, whereas the posterior lamella includes the
tarsal plate, capsulopalpebral fascia, and conjunctiva. The lid
skin is extremely thin with minimal subcutaneous fat, in con-
tradistinction to the cheek skin which is thicker with a more
substantial subdermal fat layer. Directly beneath the lid skin
sits the orbicularis muscle which is innervated by CN VII
and responsible for eyelid closure. The orbicularis muscle is
761
762
divided into orbital and palpebral portions, with the palpe-
bral portion further subdivided into pretarsal and preseptal
parts. The pretarsal fibers coalesce with other support
structures medially and laterally to create the medial and lat-
eral canthal tendons. The orbital portion of the infraorbital
orbicularis muscle originates from the maxilla. Along with
preseptal orbicularis muscle fibers, it inserts laterally along
the lateral orbital rim and provides a stable anchor point for
the lower lid margin (Fig. 2). Dynamic activity of the orbicu-
laris and overlying skin perpetuated over years results in fine
rhytids in the infraorbital and lateral canthal region. Loss of
skin elasticity and ultraviolet damage also factor into wrinkle
formation of periocular skin.
Support for the lower lid arises from the posterior lamella,
specifically the tarsoligamentous sling comprised of the tar-
sal plate and canthal ligaments which insert into bony perios-
teum medially and laterally (Fig. 3). The lower lid tarsal
plate has an average height of 4 mm and is 1 mm thick.
Anteriorly it is covered by the orbicularis muscle and poste-
riorly lined by conjunctiva that continues on to the globe as a
scleral covering. It inserts into Whitnall’s lateral tubercle
located within the lateral orbital rim. Eisler’s fat pad sits
superior to Whitnall’s tubercle and can be a useful guide for
canthoplasty suture placement along the lateral orbital rim.
The medial canthal tendon is divided into an anterior and
posterior reflection separated by the lacrimal sac. The deep
reflection extends from the nasal portion of the tarsal plate to
the posterior lacrimal crest and is the true support for the
natural convex curve of the lower lid. The anterior reflection
blends with pretarsal orbicularis fibers and extends anteri-
orly to the lacrimal sac fossa. The lateral canthal tendon is a
single reflection structure which arises from the lateral tarsal
plate and inserts into the lateral orbital tubercle posterior to
the orbital rim, usually measuring 5–7 mm in length (Fig. 4).
Its posterior attachment maintains the curve of the globe.
Portions of the lateral horn of the levator aponeurosis, lateral
rectus check ligaments, and Whitnall’s and Lockwood’s liga-
ments also coalesce to help form the lateral canthal tendon.
While the lateral canthal ligament is a fixation point, fibrous
connections with •the check ligament of the lateral rectus
muscle impart some mobility to the lateral canthus allowing
an unobstructed lateral field with lateral gaze.
The orbital septum lies deep to the orbicularis muscle. It
attaches to the orbital rim along what is known as the arcus
marginalis. It originates deep to the lacrimal sac and essentially
encircles the entire orbit passing deep to Whitnall’s tubercle
along the inner aspect of the lateral orbital rim. Along the lower
lid, the septum fuses with the capsulopalpebral fascia and inserts
into the inferior edge of the tarsus. It ultimately extends medi-
ally up to the anterior lacrimal crest. The septum maintains peri-
orbital fat within the confines of the orbit. There are three fat
compartments along the lower lid: nasal, central, and temporal.
The inferior oblique muscle separates the nasal fat pad from the
K.A. Boehm and F. Nahai
central fat pad and is commonly visualized during lower blepha-
roplasty. The central and temporal fat pads are separated by the
arcuate expansion of Lockwood’s ligament.
Beyond the confines of the arcus marginalis lies the sub-
orbicularis oculi fat (SOOF) of the midface. This fatty layer
lies in the preperiosteal plane just deep to the orbital por-
tion of the orbicularis muscle. It is deep to the superficial
musculoaponeurotic system (SMAS) and partially overlies
the facial mimetic muscles. A second midface fatty layer,
the malar fat pad, lies in the subcutaneous plane anterior
to the orbicularis muscle (Fig. 5). The orbitomalar ligament
is the primary retaining ligament of the midface. It origi-
nates from the inferior orbital rim and extends through
orbicularis muscle fibers to insert into the dermis. The
integrity of the orbitomalar ligament maintains a youthful
lid-cheek junction. The indentation of the tear trough defor-
mity is attributable to the arcus marginalis, orbitomalar
ligament, orbicularis muscle, levator labii superioris, and
levator alaeque nasi muscles. Descent of the SOOF over
time leads to increased visibility of the inferior orbital rim
and a defined lid-cheek junction that is a hallmark of peri-
orbital aging (Fig. 6). Consequently, surgical techniques to
correct midface aging often rely on division of the orbito-
malar and zygomatic cutaneous ligaments and resuspen-
sion of the SOOF to correct nasojugal hollowness and mask
the lid-cheek junction.
While the orbicularis muscle serves to close the lid, the
lower lid retractors act to open the lid. Although the lower lid
is not as dynamic a structure as the upper lid, the lid nonethe-
less depresses with downgaze and shifts horizontally with
routine blinking. The capsulopalpebral fascia in the lower lid
is analogous to the levator aponeurosis in the upper lid. It
originates from the inferior fascia and lies atop the inferior
tarsal muscle. A portion of the capsulopalpebral fascia trav-
els to the inferior fornix to become Tenon’s fascia which
extends onto the globe. Other strands insert at the base of the
tarsus along with the inferior tarsal muscle and orbital sep-
tum. Additional strands penetrate the orbicularis and insert
onto the lower lid dermis creating the lower lid crease. The
capsulopalpebral fascia also fuses with Lockwood’s liga-
ment, an important support structure for the globe.
Primary vascular supply to the lower lid arises from the
internal maxillary artery off of the external carotid. This
becomes the infraorbital artery which penetrates through
the infraorbital foramen. It anastomoses with branches of
the dorsal nasal artery to supply the lower lid. Tarsal arcades
based primarily medially from the inferior palpebral artery
travel along the lower lid margin as well. They anastomose
laterally with the lacrimal and zygomatic facial branches of
the superficial temporal artery. This arcade is located 4 mm
inferior to the ciliary margin. Surgical maneuvers including
lower lid blepharoplasty incisions and lid sharing flap
incisions that are placed below this 4 mm preserve the
Lower Eyelid Blepharoplasty 763

Fig. 1 External features of the aging

periorbita

orbital fat atrophy

descent of brow
blunting of scleral triangle
lower lid laxity
lower lid fat herniation
nasojugal groove
mid cheek groove
malar mound
tear trough deformity
nasolabial fold

youthful face aging face

frontalis muscle
orbital portion, orbicularis oculi muscle

preseptal portion, orbicularis oculi muscle

lateral raphe
pretarsal portion, orbicularis oculi muscle

transverse part, nasalis muscle levator anguli oris muscle

levator labii superioris alaeque nasi muscle zygomaticus minor muscle

zygomaticus major muscle
levator labii superioris muscle

Fig. 2 Muscle anatomy in the lower lid region

764 K.A. Boehm and F. Nahai

arcade and lid margin viability. Additionally, because the
blood supply is based predominantly medially, interruption
of lateral blood supply such as with a lateral canthotomy
can be done safely without jeopardizing lower lid circula-
tion. The anterior facial vein is the main structure for
venous outflow. The facial vein becomes the angular vein in
the region of the medial canthus where it ultimately forms
a deep anastomosis with the superior ophthalmic vein. The
inferior ophthalmic vein traverses the inferior orbital fis-
sure to empty into the pterygoid plexus which communi-
superior tarsal
plate
medial canthal
Whitnall's
tubercle
tendon
inferior tarsal plate
lateral canthal tendon
Fig. 3 Tarsoligamentous support structures of the lower eyelid
cates directly with the cavernous sinus. Lymphatic drainage
is based either medially or laterally. The nasal portion of
the lower eyelid drains along lymphatics that parallel the
course of the facial vein and ultimately into the subman-
dibular lymph nodes. The lateral half drains into the preau-
ricular nodal basin.
The maxillary division of cranial nerve V is the sensory
root to the lower lid. It branches into the infraorbital nerve
which exits through the infraorbital canal and ultimately
gives rise to terminal branches along the lower lid margin.
The zygomatic facial nerve emerges along the inferior lateral
orbit and supplies additional sensation to the lateral lower
lid. Motor innervation to the orbicularis oculi muscle origi-
nates from branches of the facial nerve, primarily the frontal,
zygomatic, and buccal branches (Fig. 7).
Rejuvenative surgical procedures such as a lower lid
blepharoplasty attempt to reverse visible changes that
occur over time. These changes are an external reflection
of altered anatomy that occurs in response to several fac-
tors including environment, sun exposure, and genetic
predisposition. Particularly in the periorbital region,
structural changes such as decreased elasticity, volume
deflation, and tissue descent manifest themselves in con-
sistent ways that confer an aged appearance. Specifically
in the periorbita, the lower eyelid and midface region
intersect as one aesthetic unit. Senescent changes seen
along the lower lid are accompanied by similar type
changes in the cheek region.
Over time, the skin of the lid region will undergo both
microscopic as well as more macroscopic changes. Sun
exposure, smoking, and dynamic activity like smiling will
exert their influences on the already thin lower lid skin and
cause decreased elasticity. Wrinkles in the form of lateral
canthal rhytids and infraorbital “crepey-like” skin will

Fig. 4 Axial view of bony orbital septum

insertions of tarsoligamentous medial
slings canthal
tendon
pretarsal portion, lacrimal sac
orbicularis oculi
muscle orbital fat

inferior
tarsal ethmoid sinus
plate

skin and
subcutaneous
fat

lateral canthal
tendon
Lower Eyelid Blepharoplasty 765

Tenon's fascia

Lockwood's
ligament

lower lid tarsal plate

retractor
capsulopalpebral
fascia supraorbital nerve

orbital septum supratrochlear nerve

orbital fat
zygomaticotemoral nerve

orbicularis oculi zygomaticofacial nerve

muscle
SOOF
infraorbital nerve
orbitomalar
ligament
SOOF
inferior orbital rim

malar fat pad

Fig. 5 Fat compartments in the lower lid region Fig. 7 Nerve supply in the periorbital region

Infraorbital hollowing
SOOF
deepening of the malar fat pad
nasolabial fold secondary
to fat descent

Fig. 6 Descent of lower lid fat and resultant changes

malar festoons

become manifest. Conditions that cause repeated swelling or

inflammation will also alter tissue elasticity and resilience.
The result is an increase in redundant, inelastic, stretched
skin. At the more severe end of the spectrum, patients can
present with malar festoons, redundant folds of lax skin and
orbicularis muscle of the lower eyelids that extend from can-
thus to canthus. In these cases, attenuation of the orbicularis
oculi muscle in combination with laxity between the orbicu-
laris and the deep fascia allows the muscle and overlying
skin to progressively sag until multiple folds become sus-
pended across the infraorbital rim (Fig. 8). Fig. 8 Artistic depiction of malar festoons
766
With age, the orbital septum loses integrity as well. The
weakened septum allows anterior protrusion of the orbital
fat, manifest as infraorbital fat pad prominence or “palpebral
bags”. This fat protrusion will contribute to further thinning
and lengthening of the overlying orbicularis muscle, thereby
worsening infraorbital hollowing and increasing the vertical
distance from lower lid to cheek margin.
Several orbicularis retaining ligaments affix the orbicu-
laris muscle to the inferior orbital rim. These ligaments have
greatest length along the central portion of the rim, and
decrease in length when moving medially or laterally. The
orbitomalar ligament is the primary supportive ligament. It
extends from the inferior orbital rim, through the orbicularis
muscle, and into the dermis. As it lengthens over time and
descends, formation of a well defined lid cheek junction
results. Laterally, the orbicularis is attached to the frontal
process of the zygoma and the lateral canthal tendon. The
zygomatic facial ligaments retain the malar fat pad and cheek
skin to the underlying zygoma. These normally dense sus-
pensory attachments attenuate over time and the orbicularis
muscle loses tone, leading to descent of the midface and
inferior migration of cheek skin. Ptosis of the malar fat pad
and deepening of the nasolabial sulcus result. With soft tis-
sue descent, the bony infraorbital rim becomes exposed and
more visible, leading to a well defined lid-cheek junction as
opposed to a more smooth transition between the two struc-
tures. Successful rejuvenative procedures often rely on
release, elevation, and resuspension of such tissues for cor-
rection of these changes.
With age, the canthal tendons stretch allowing the once
taut lid to sag and become more easily distracted away from
the globe. The other skeletal support along the lid margin,
the tarsal plate, also weakens over time. The diminished tone
along the lower lid ultimately alters lower lid position and
eye fissure shape. The tarsoligamentous laxity, coupled with
orbicularis atrophy and lengthening of the orbicularis retain-
ing ligaments, can lead to inferior migration of the lid margin
itself, manifest as inferior scleral show, an increased lateral
scleral triangle, and ectropion in more severe cases. Patients
with prominent eyes are particularly predisposed to this
downward migration and scleral show development. In such
cases, the eye assumes a more round shape as opposed to the
almond shape seen in youth.
The tear trough deformity refers to the triangular perior-
bital hollowing along the inner canthus. It is often one of the
earliest signs of periorbital aging. It initially develops as a
concavity where the orbicularis muscle attaches to the bony
orbital rim. Anatomically, this concavity is defined by the
orbital portion of the orbicularis muscle, the levator labii
superioris, and the levator alaeque nasi muscle. There is
scant subcutaneous tissue between the skin and orbicularis in
the tear trough region and the tear trough hollowness reflects
thin skin adherent to underlying muscle. With continued
K.A. Boehm and F. Nahai
aging, the hollowing will progress from medially to laterally
and in most advanced cases appear as a circumferential hol-
lowness along the entire infraorbital rim.
3 Surgical Techniques
Aging changes of the infraorbital and midface region are
treated with a lower lid blepharoplasty. Various refinements
of the technique can be incorporated to address the specific
anatomic changes present in an individual, including fat her-
niation, infraorbital hollowness, skin wrinkling, midface
descent, and malar festoons. Approaches to lower lid rejuve-
nation are numerous. Incisions alone can be transconjuncti-
val, externally cutaneous, or endoscopic [2]. Lower lid fat
can be treated with removal, redraping, or transfer. Some
routinely combine lower lid blepharoplasty and subperios-
teal midface whereas others do not. The specifics of what
technique to apply lie in accurate preoperative assessment of
anatomic deformities as well as surgeon’s level of comfort
with performing the required surgical maneuvers [3, 4].
Most blepharoplasty patients present with some degree of
skin excess or redundancy and thus necessitate an external
incision for skin removal or redraping. A lateral incision is
made with a #15 blade in one of the natural rhytids in this
region. Bovie is used to dissect through muscle to perios-
teum along the lateral orbital rim. Scissors are introduced
through this incision to undermine the skin and muscle
immediately below the lower lid lashes and tarsal plate. The
scissors are then turned and cut the skin and muscle to com-
plete the subciliary incision (Fig. 9). A four prong retractor is
placed to stabilize the inferior cut edge while the needle tip
cautery dissection elevates a skin-orbicularis flap off of the
underlying septum (Fig. 10a). This preseptal dissection is
carried down to the infraorbital rim. At the level of the rim,
the cautery is turned deeper to dissect in the preperiosteal
plane. Dissection is continued over the inferior orbital rim,
releasing the orbitomalar ligaments, and over the malar emi-
nence, freeing the arcus marginalis (Fig. 10b). These maneu-
vers will allow greater mobilization of the skin-muscle flap
and superior elevation of the suborbicularis oculi fat. Inferior
dissection is performed for approximately 1 cm in the course
of the extended lower lid blepharoplasty. Care should be
taken to preserve the infraorbital and zygomatic facial nerves
so as to maintain sensation over the mid-cheek and malar
region (Fig. 11).
At this point attention is turned to the three lower lid fat
pads. The septum overlying the fat pads is incised either with
cautery or sharp scissors. Digital pressure on the globe can
help to define the fat pads by herniating them anteriorly. The
fat contents are gently freed from their postseptal pockets.
The inferior oblique muscle responsible for lateral rotation,
elevation and abduction of the globe is located between the
Lower Eyelid Blepharoplasty
Fig. 9 Intraoperative view of subciliary incision using curved sharp
scissors to divide skin and orbicularis muscle
b Fig. 12 Fat along the lower lid being released from its postseptal
Fig. 10 (a) Elevation of lower lid skin muscle flap using needle tip
cautery. (b) At the level of the infraorbital rim, preperiosteal dissection
is performed to release all overlying ligaments and attachments
central and nasal fat pads; care should be taken to avoid
injury to this structure. In situations where there is excep-
tional prominence of the infraorbital fat pads, partial exci-
sion will improve the overall infraorbital contour. This is
767
Fig. 11 The infraorbital nerve seen medially is preserved during the
course of the preperiosteal dissection
pocket and conservatively trimmed with cautery
done by grasping the fat with forceps and trimming with cau-
tery, making sure all vessels are cauterized (Fig. 12). The
more recent trend is preservation and redraping of fat.
Specifically in this region, the fat can be transferred to lie
over the inferior orbital rim to camouflage the lid-cheek
junction and create a more convex contour [5–7].
The released central and lateral fat pockets are draped
over the inferior orbital rim and tacked to the preserved peri-
osteum using 6-0 vicryl sutures. In addition to blunting the
lid and midface transition, orbital fat fills the hollowness
associated with periorbital volume loss and the tear trough
deformity. The depression as it extends from the medial orbit
to the lateral canthus is exposed with the preperiosteal dis-
section along and inferior to the lower orbital rim. All
ligamentous attachments overlying the tear trough are
released; insertion of a Desmarres retractor can assist in pro-
viding adequate exposure of the medial orbital rim. The
nasal fat pad can be transposed into the triangular depression
768 K.A. Boehm and F. Nahai

a defined by the orbicularis oculi, levator labii superioris, and

b a canthoplasty, cantholysis and lid shortening is performed
Fig. 13 (a) The ligamentous attachments in the tear trough region are
released with cautery to create a pocket for fat insertion. (b) The nasal
fat pad is transposed into the tear trough to provide bulk and volume
levator alaeque nasi. The 6-0 vicryls can once again be used
to tack this fat to intact rim periosteum (Fig. 13a, b). If addi-
tional fill is needed, the central fat pad can be transferred in
a similar manner.
Lateral canthal fixation is performed next and is an essen-
tial step in performing safe lower lid blepharoplasty and
minimizing risk of postoperative lid malposition [8–10].
Canthal anchoring assists in controlling the shape of the eye-
lid fissure and counteracting cicatricial healing forces which
pull the lower lid inferiorly and lead to scleral show. Options
for canthal fixation include canthopexy and canthoplasty.
A canthopexy involves direct fixation of the lower lid to the
orbital rim without disruption of the lower canthal tendon. In
prior to fixation of the lid margin to the orbital rim. In both
cases, the new canthus is affixed inside the orbital rim
thereby allowing the lid to follow the natural curve of the
globe (Fig. 14a, b). The decision to perform a canthopexy
versus a canthoplasty is one that can be made intraopera-
tively based on the degree of lid laxity. If using a forceps to
tuck the lateral lid margin against the orbital rim adequately
corrects the lid excess, then a canthopexy alone is adequate.
If this maneuver does not result in adequate lid tension, the
patient will benefit from lid shortening and formal cantho-
plasty. In general, if the lid margin is only able to be dis-
tracted 3–4 mm from the globe, canthopexy will suffice,
whereas canthoplasty will benefit those with more signifi-
cant lid laxity (Fig. 15).

lateral orbital wall

a b
lateral canthal tendon periosteum inner aspect incised edge of the
lateral orbital wall inferior tarsal plate
periosteum along
inner aspect
lateral
orbital wal

lateral retinaculum lateral retinaculum incised lateral canthal tendon

orbicularis muscle

Fig. 14 (a) Artistic rendering of canthopexy. Lateral canthal tendon remains intact. (b) Depiction of canthoplasty. Note that lower lid is affixed to
the inner aspect of the lateral orbital rim
Lower Eyelid Blepharoplasty
Fig. 15 Intraoperative assessment of lower lid laxity using forceps to
distract lid margin from the globe
A canthopexy is done by using an 11 blade to nick the
conjunctival surface along the lateral lower lid. A 4-0
Mersilene or Prolene double-armed horizontal mattress
suture is placed through the tarsal plate, through the nicked
conjunctiva and back out anteriorly. A 6-0 vicryl is then
placed at a 90° angle to this through a portion of the tarsus
and around the canthopexy suture as a locking stitch to pre-
vent cheese wiring of the Prolene through the tarsal plate.
The two arms of the canthopexy suture are then placed along
the inner aspect of the lateral orbital rim periosteum. By
passing the sutures deep to superficial the canthus is pulled
posteriorly and superiorly, avoiding a bowstring type defor-
mity. The distance between the two arms of the suture should
correspond to the width of the tarsal plate. Tying the suture
arms should correct lid laxity and maintain a lower lid posi-
tion 1–2 mm above the inferior limbus. If tied too tightly,
clotheslining of the lid below the globe can occur; this is
corrected by loosening the suture and stretching the lid supe-
riorly to desired level (Fig. 16).
A canthoplasty integrates cantholysis of the inferior can-
thal tendon to physically divide the upper and lower lid can-
thal tendons. The freed lid margin is held against the lateral
orbital rim and the amount of redundancy assessed. Straight
sharp scissors are used to perform a full thickness excision of
the redundant lid, usually measuring 2–4 mm. The same
double-armed 4-0 Mersilene or Prolene is passed inferiorly
to superiorly along the cut edge of the tarsal plate. Once
again, each arm of the suture is passed from deep to superfi-
cial along the lateral orbital rim periosteum at the level of the
midpupillary line and tied to reestablish lid fixation. The 6-0
fast absorbing plain is then used to tack the anterior aspect of
the lower lid gray line to the posterior aspect of the upper lid
gray line in an effort to recreate a sharp lateral canthal angle.
In choosing the point of lateral canthal fixation the relation
of the anterior globe to the inferior orbital rim should be taken
769
Fig. 16 The two arms of the canthopexy suture are being tied down.
Note the decreased lower lid laxity when attempting to use the forceps
to pull the lid margin away from the globe
into account. In cases of a negative vector, the globe is essen-
tially anterior to the bony orbit. Such is the case in patients
with prominent eyes or a recessed malar area [11]. By con-
trast, patients with deep set eyes or a prominent bony orbit
exhibit a positive vector. Those with a negative vector are pre-
disposed to downward displacement of the lid following lower
lid blepharoplasty. Placing the canthoplasty slightly higher
along the lateral orbital margin can counteract this tendency.
If supraplacement of the canthoplasty stitch fails to ade-
quately elevate the lid level, insertion of a spacer graft may
be necessary. Following canthoplasty placement, the lower
lid retractors and conjunctiva are divided with the Bovie,
below the level of the inferior arcade usually 4 mm inferior
to the lid margin. The spacer material is then sewn along the
posterior lamella to physically elevate the lid margin.
Materials used can include Enduragen, Alloderm, or autog-
enous ear cartilage. The spacer material is cut to the desired
height needed for support of the cut lid margin. It is inserted
into the newly created space and sewn inferiorly and superi-
orly to the edges of the posterior lamella using 6-0 plain.
At this point, the skin muscle flap is pulled in a superior
lateral vector to smooth the infraorbital skin. The area of
excess at the lateral extent is conservatively marked as a tri-
angle (Fig. 17). The area of redundancy is deepithelialized to
create a lateral pennant of orbicularis muscle that can be
anchored to the lateral orbital rim and provide solid suture
fixation of the lower lid during the postoperative healing
phase (Fig. 18). A suture is placed through the muscle and
then tacked to the periosteum along the anterior aspect of the
lateral orbital rim (Fig. 19a, b). Any excess muscle is
trimmed. This recreates the natural concavity in the lateral
lid region and acts as an additional means to counteract the
downward forces that occur along the lower lid postopera-
tively. Any skin muscle excess along the lid margin itself is
also excised with curved sharp scissors, taking care to avoid
770 K.A. Boehm and F. Nahai

Fig. 17 The skin muscle flap is pulled superiorly and area of excess b
marked

Fig. 19 (a) The suture is passed through the inferior aspect of the mus-
cular pennant. (b) The muscle is then tacked to the anterior aspect of the
lateral orbit rim to reinforce lateral stability to the lower lid

Fig. 18 Deepithelialization of the lateral skin triangle

overresection (Fig. 20). A running 5-0 Prolene is used to

close the subciliary and lateral canthotomy incisions. The
postoperative regimen includes generous use of ocular lubri-
cants. Typically this includes artificial tears during the day,
and a steroid/antibiotic ophthalmic combination ointment at
night. Oral steroids, cool compresses, and head elevation are
useful to minimize swelling. Suture removal is performed 7
days following surgery.

4 Complications Fig. 20 Conservative excision of elevated skin muscle flap

The most dreaded complication following lower lid blepha-
roplasty is also the most common: lower lid malposition. The
spectrum of lower lid malposition includes scleral show,
round eye syndrome, and ectropion. In addition to the aes-
thetic deformity, these positional changes can lead to dry
eyes and exposure keratitis. Effective correction relies on
tightening the lateral canthus to elevate the lid and recreate
the lateral canthus [12].
While intraoperative correction of horizontal lid laxity
and conservative skin excision minimize complication risk,
several other factors alone or in combination can predispose
to postoperative lid malposition. These factors include failure
Lower Eyelid Blepharoplasty
of the lateral canthal suture fixation, excessive edema or
hematoma, cicatricial scar formation, and skin overresection.
Additionally, a negative vector such as in those with globe
proptosis or midface hypoplasia predisposes a patient to this
problem due to the inherent imbalance of lower lid support
mechanisms. The combination of globe prominence coupled
with poor lid tone places a patient at particular high risk for
lid position complications.
In cases of lid malposition, a majority of patients will
respond to conservative treatment initiated in the early postop-
erative period. These regimens include lower lid upward mas-
sage and lid taping with Steri strips. Stretching the lower lid
superiorly against the curve of the globe can also be helpful. In
cases where a patient is experiencing symptomatic corneal
exposure, a tarsorrhaphy suture can be placed under local anes-
thesia and left in place for several weeks. This in combination
with ocular lubrication can alleviate the symptoms and allow
time for conservative maneuvers to correct the malposition.
The key to correction is proper identification of the ana-
tomic cause of the lid malposition. The establishment of ade-
quate lid support is essential when performing transcutaneous
blepharoplasty. Both canthopexy and canthoplasty techniques
fix the lateral lid to the periosteum along the inner aspect of
the lateral orbital rim in an attempt to stabilize lid position.
Lateral canthal fixation has proven useful to not only prevent
lower lid problems but to also correct them when they occur.
Therefore, in cases where lateral canthal fixation was not ini-
tially performed or technical failure of the suture is suspected,
lateral canthoplasty should be performed.
Overzealous skin resection at the initial blepharoplasty
leads to skin shortage which can overcome even solid tarso-
ligamentous support and pull the lid down. Anterior lamellar
deficiency from aggressive skin resection can be identified
by noting lower lid movement with mouth opening. Most
cases respond to stretching exercises, but those that do not
will usually require skin grafting.
In more severe cases, the level of scarring is not merely at the
level of the skin but deeper along the orbital septum and capsu-
lopalpebral fascia. This is particularly true in cases where the lid
malposition is not limited to the lateral canthal region and
includes the central portion of the lower lid. In these situations,
the scarred structures need to be completely released and the lid
margin elevated to the desired position in relation to the inferior
limbus. To maintain adequate support to the lower lid and cor-
rect vertical lamellar deficiency, a spacer graft must be inserted
into this newly created space. The spacer is sewn to the cut
edges of the released retractors. Use of material such as a human
acellular dermal matrix or porcine acellular dermis can avoid
potential donor site morbidity, albeit with somewhat increased
likelihood of graft resorption. In general, 2 mm of inserted graft
will ultimately translate into 1 mm of corrected vertical height.
Lateral canthal fixation should be incorporated to anchor the lid
and correct any tarsoligamentous laxity which could also
771
contribute to postoperative lid malposition. In some cases of
multiple reoperations, there may be insufficient lateral orbital
periosteum to affix to suture canthoplasty. A drill hole cantho-
plasty may be necessary. Drill holes are created along the lateral
orbital rim and the tarsal plate suture needles may be passed
through these for fixation to the bony orbit.
Hematomas usually originate from bleeding orbicularis
oculi muscle. With the exception of an expanding hematoma,
these do not usually require reoperation and can be managed
with warm compresses to promote liquefaction and resorp-
tion. More serious is postseptal bleeding. True retrobulbar
hemorrhage is rare with an incidence less than 1 %, but early
recognition is imperative to avoid permanent visual loss.
Ongoing orbital bleeding increases intraocular pressure
which if severe enough can lead to ischemia of the retina and
optic nerve. Presentation is usually within 24 h of surgery.
Symptoms include severe pain and visual disturbances, and
clinical manifestations include proptosis, decreased visual
acuity, altered papillary and extraocular movements, and
increased intraocular pressure. Immediate operative inter-
vention is necessary. Surgical decompression includes suture
removal, lateral canthotomy and cantholysis, and control of
active hemorrhage. Orbital bony decompression is a last
resort when organized clot is identified posteriorly [13].
Chemosis refers to a condition in which the conjunctiva
swells and retains fluid. The edematous conjunctiva prevents
adequate tear dispersion and a dellen, or corneal dry spot,
occurs. The etiology is likely lymphatic drainage obstruction,
incomplete eyelid closure with corneal exposure or inflamma-
tion, alone or in combination. If recognized intraoperatively,
the conjunctiva can be snipped to decompress the edema. The
postoperative treatment regimen focuses on ocular lubrication
with a combination of artificial tears and ointment. A topical
steroid drop can be used to suppress inflammation. If severe or
persistent, the globe can be anesthetized with topical anesthetic
drops and the distended conjunctiva cut with scissors for
decompression. The eye should be patched following this.
The rich vascularity of the periorbita makes postoperative
infection a rare occurrence. The presentation of erythema and
tenderness in the initial weeks following blepharoplasty will
usually be attributable to a staph or strep infection. Treatment
with a 7–10 day course of oral antibiotics is appropriate.
Infections that present more than 6 weeks after surgery are
usually the result of more atypical organisms, namely myco-
bacteria. Confirmation by culture can be difficult and rather
prolonged in these cases. Treatment with ciprofloxacin should
be initiated, though clinical resolution can be rather protracted.
An important distinction is that of differentiating a postopera-
tive infection from an inflammatory reaction, particularly as
the treatment regimens differ. The presence of redness with
firm, subcutaneous nodules should raise suspicion of an
inflammatory granulomatous reaction, often in response to the
presence of a foreign body such as suture or ointment or even
772
liquefied fat. Treatment in this situation is steroids, in contra-
distinction to those cases attributable to an infectious etiology.
Resolution may take several months. Intralesional steroid
injections and granuloma excision can be considered once the
nodules have become mature and discreet.
Conclusion
As is often the case in plastic surgery, the best surgical out-
comes can go unnoticed. In the case of lower lid blepharo-
plasty, this translates into youthful restoration of the lower lid
and cheek region with maintenance of a natural lower lid
position. Complications such as round eye syndrome, scleral
show, and ectropion bear both functional and aesthetic con-
sequences to patients. Understanding the precise anatomic
changes in an individual and incorporating steps that stabi-
lize lid position in the setting of lower lid blepharoplasty are
essential to minimizing postoperative complication risk.
Bibliography
1. Zide BM, Jelks GW (2006) Surgical anatomy around the orbit.
Lippincott, Philadelphia
2. Pacella SJ, Nahai FR, Nahai F (2010) Transconjunctival blepharo-
plasty for upper and lower eyelids. Plast Reconstr Surg 125(1):
384–392
K.A. Boehm and F. Nahai
3. Nahai F (2005) Clinical decision making in aesthetic eyelid sur-
gery. In: Nahai F (ed) The art of aesthetic surgery. Quality Medical
Publishing, St. Louis
4. Cardosa de Castro CC (2004) A critical analysis of the current sur-
gical concepts for lower lid blepharoplasty. Plast Reconstr Surg
114:785–793
5. De Castro CC, Boehm KA (ed) (2009) Midface surgery. In:
Techniques in aesthetic plastic surgery. Elsevier, Philadelphia
6. McCord CD, Codner MA (2008) Eyelid and periorbital surgery.
Quality Medical Publishing, St. Louis
7. Hester TR (2005) Midface rejuvenation. In: Nahai F (ed) The art of
aesthetic surgery. Quality Medical Publishing, St. Louis
8. Codner MA, Wolfi JN, Anzarut A (2008) Primary transcutaneous
lower blepharoplasty with routine lateral canthal support: a com-
prehensive 10 year review. Plast Reconstr Surg 121(1):241–250
9. McCord CD, Boswell CB, Hester TR (2002) Lateral canthal
anchoring. Plast Reconstr Surg 112:222–237
10. McCord CD, Ellis DS (1993) The correction of lower lid malposi-
tion following lower lid blepharoplasty. Plast Reconstr Surg 92:
1068–1072
11. Hirmand H, Codner MA, McCord CD et al (2002) Prominent eye:
operative management in lower lid and midfacial rejuvenation and
the morphologic classification system. Plast Reconstr Surg 110:
620–628
12. Boehm K, Nahai F (2008) Complications of lower lid blepharo-
plasty. In: Park D (ed) Cosmetic and reconstructive oculoplastic
surgery, 2nd edn. Koonja Publishing Inc., Seoul
13. McCord CD, Shore JW (1983) Avoidance of complications in
lower lid blepharoplasty. Ophthalmology 90:1039–1046
 Blepharoplasty: Minimally Invasive
Approach
Nicolò Scuderi and Luca A. Dessy
1 Introduction
The orbit and the surrounding tissues constitute the emo-
tional and expressive part of the human face. The visual con-
tact represents a large part of human interactions and,
unfortunately, this area is among the first to surrender to the
ageing process.
The blepharoplasty is one of the most commonly per-
formed procedures in cosmetic surgery. An attentive preop-
erative evaluation allows to safely obtain satisfying results.
The objective of the surgeon is to obtain a natural, aestheti-
cally pleasant appearance without noticeable signs of
surgery.
The evolution of cosmetic surgery treatments led to the
development of less invasive techniques that offer the advan-
tage of being easier and faster and that allow to reduce the
patients recovery time, therefore accelerating the return to
everyday life. These minimally invasive techniques allow to
obtain natural, effective, long-lasting results with a decrease
in risk of complications [1, 2].
This chapter presents the minimally invasive techniques
of lower blepharoplasty that, when appropriately selected,
produce significant and effective results reducing the risk of
complications. The following approaches are described: the
preseptal and retroseptal transconjunctival approach to the
lower eyelid, the treatment of lower eyelid skin excess by
pinch technique or other ancillary treatments. The pioneer of
this minimally invasive approach was Glenn Jelks, who
named this kind of blepharoplasty ‘no touch’ blepharoplasty
[3, 4]. In this kind of surgical procedure, indeed, the pretarsal
portion of the orbicularis oculi muscle is not touched so as to
preserve the shape and function of the eyelid and reduce the
onset of lower eyelid malposition.
N. Scuderi, MD • L.A. Dessy, MD (*)
Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
e-mail: nicscuderi@gmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_55
2 Preoperative Evaluation
It is always necessary that patients undergo ophthalmic eval-
uation before blepharoplasty and orbito-palpebral surgery.
This helps in identifying the presence of possible concomi-
tant pathologies that require specific therapy, or that can be a
relative or absolute contraindication to surgery and, if not
noticed before surgery, can represent the object of a medico-
legal debate [5]. During the ophthalmology visit, it is impor-
tant to evaluate the visual acuity, the intraocular pressure and
the fundus oculi (in case of diabetes and hypertension).
Then, it is important to investigate possible abnormalities of
the ocular globe (exophthalmos and palpebral asimmetries,
proptosis, corneal scars). Afterwards, tear secretion is evalu-
ated through the Shirmer’s test and finally the presence of
local infections (blepharitis, chalazion) is ruled out.
In order to evaluate the indication for blepharoplasty and
to choose the most appropriate technique, the surgeon should
then evaluate the following characteristics:
• Quantity and characteristics of palpebral skin: It is
important to evaluate the skin excess when the patients
look upwards. This manoeuvre stretches the skin giving
the surgeon an idea of how much skin excess is present. If
the evaluation of the skin excess is performed only with
the patient looking frontally or downwards, after the skin
removal an ectropion may develop.
• Presence of adipose tissue pseudoherniation: It is impor-
tant to evaluate the three lower eyelid fat bags for the
presence of pseudoherniation. This evaluation is also bet-
ter performed with the patient looking upwards. In order
to distinguish the fat herniation from the oedema, a light
pressure should be applied on the upper eyelid as the
patient looks up. The herniated fat becomes more promi-
nent with pressure, whereas in case of palpebral oedema
no change is noticed.
• Lower eyelid position below the inferior limbus: In order
to measure the lower eyelid retraction, it is fundamental
to evaluate the lateral, central and medial relationship
773
774
between the lower eyelid and the inferior limbus while the
patient is looking forward. In normal conditions, there
should be no scleral show below the limbus. In certain
individuals, the scleral show can be normal and the sur-
gery must not increase it.
• Margin Reflex Distance-2 (MRD2): This is an objective
measurement that can be carried out by pointing a light in
the patient’s eyes when they are at the same level of the
examinator’s eyes. The distance between the corneal light
reflex and the lower eyelid is normally 5.5 mm but it
increases in patients with ectropion. The difference
between the normal and the measured MRD2 can give an
indication on how much skin is needed to correct the
ectropion caused by the deficit of the anterior lamella.
• Presence of a hypertrophic orbicularis oculi muscle: A
hypertrophic muscle can appear as an evident strip in the
lower eyelid.
• Lid tone: It is important to assess the lid tone with the
snap test and the laxity of the lateral canthus.
• Snap test: The eyelid is pulled downwards and the time to
come back to the normal position is measured. Less than
one second (without blinking) is normal.
• Distraction test: If the lower eyelid can be pulled more
than 7 mm from the ocular globe, lid laxity can be
present.
• Pinch test: The lateral canthus is pulled medially. A mini-
mal movement is typical of a normal eyelid. When there
is skin laxity, the canthus can be moved more than 2 mm.
• Negative vector: The relationship between the cornea and
the inferior orbital margin is evaluated from the lateral
view. In most patients, a vertical line unites the cornea to
the inferior orbital margin. In patients with a negative
vector, the inferior orbital margin is posterior to this line.
Such patients can be at risk for lower eyelid malpositions
(increase in the scleral show), as well as for a sunken
appearance after blepharoplasty if the fat repositioning is
not correctly performed.
3 Transconjunctival Lower
Blepharoplasty
First described by J. Bourguet [6], the transconjunctival
approach for lower blepharoplasty has been used by several
authors for more than 20 years [7]. More recently, most plas-
tic surgeons confirmed their interest for the transconjunctival
approach that allows to eliminate the presence of external
scars and the possible complications of the transcutaneous
approach [5, 8–13].
The use of the transconjunctival incision allows, besides
the elimination of the external scar, to reduce the risk of eye-
lid margin distortions, which is one of the main problems of
traditional lower blepharoplasty. The herniated periorbital
N. Scuderi and L.A. Dessy
fat protruding in the palpebral bags is eliminated or reposi-
tioned through a direct access route that must not pierce the
superficial muscular layers.
In the transconjunctival lower blepharoplasty, it is possi-
ble to use two access routes: the retroseptal and the
preseptal.
• The retroseptal route is indicated in certain categories of
subjects: young patients with periorbital fat herniation
and a good musculoaponeurotic system; older patients
with adipose tissue excess, fine surface lines and reduced
lid tone. In case of slight skin excess, skin rejuvenation
should be performed by chemical peeling or laser resur-
facing. In case of heavy skin excess, it is necessary to
associate its removal with a cutaneous flap by the ‘pinch
blepharoplasty’ or the traditional transcutaneous
blepharoplasty.
• The preseptal route can be indicated in cases where it is
necessary a periorbital fat redistribution alternative to its
removal. This access can also be indicated in patients
with a high risk of dischromic, hypertrophic or keloid
scars.
3.1 Anaesthesia
Usually, transconjunctival inferior blepharoplasty is per-
formed under local anaesthesia. A few drops of topical
anaesthetic (ossibuprocaine) are instilled into the inferior
conjunctival cul-de-sac in order to anaesthetize cornea and
conjunctiva. A 2 cc local injection of 0.5 % lidocaine with
1‰ epinephrine is performed below the orbital rim near to
the emergence of the suborbital nerve, the orbital floor and
below the conjunctiva from the medial to the lateral canthus.
If an upper blepharoplasty or a canthoplasty is associated,
the patient is sedated 1 h before (atropine + diaze-
pam + hydroxyzine). In case of anxious patients or long pro-
cedures (e.g. when the operation is associated with a face
lift), the operation is performed under general anaesthesia.
3.2 Surgical Technique
in Transconjunctival Lower
Blepharoplasty
The surgeon stands behind the patient’s head. The patient is
placed in supine position on a plane that is inclined 20°–30°
so that the head is at a higher level compared to the pelvis
and the lower limbs (proclive or anti-Trendelenburg posi-
tion). Eye protectors of the appropriate size are applied.
After local anaesthesia, two traction sutures of 2–0 silk are
placed in the palpebral conjunctiva, which is pulled upwards
Blepharoplasty: Minimally Invasive Approach 775

to cover and protect the cornea; two other sutures are placed
on the free margin of the lid turned downwards. A palpebral
retractor (Desmarres) is useful for the manoeuvre.
The transversal incision is performed with a n° 15 surgi-
cal blade, very short iridectomy scissors with sharp points or
electrosurgical pencil with Colorado tip. The land mark is
the inferior border of the tarsal plane that looks grey through
the conjunctiva. The incision extends laterally and medially
keeping a 4 mm distance from the lacrimal point [14].

3.3 Preseptal Access

This route allows the access to the fat bags through the
orbital septum preserving the integrity of the orbicularis
Fig. 1 Schematic drawing of the conjunctival incision with the presep-
oculi muscle and the skin. Through this approach, it is also tal approach
possible to reach the orbital margin and, from this, the medial
third of the face. The incision is placed 2 mm below the infe-
rior border of the tarsal plane (Fig. 1). The incision starts at
4 mm from the lacrimal point and reaches the lateral canthus
and can go beyond if a canthoplasty is associated. Bipolar
cautery forceps are used for the haemostasis of the conjunc-
tiva. The control of bleeding should be meticulous in order to
consent a correct vision of the anatomical planes for
dissection.
The cornea is protected by the conjunctival flap and the
assistant pulls with a hand the two sutures fixed at the palpe-
bral margin and with the other gently pushes over the ocular
globe in order to make the palpebral bags protrude. After the
incision of the conjunctiva and the capsulopalpebral fascia,
the dissection of the anterior aspect of the orbital septum fol-
lows an avascular plane until the retromuscular space is
reached by a smooth dissection with scissors that is contin-
ued until the inferior orbital margin (Fig. 2). The three fat
bags are visible through the septum that is now opened by
three small incisions in correspondence with the three bags
so that the adipose tissue can protrude in the dissection plane
Fig. 2 Schematic drawing showing the level of the conjunctival inci-
(as in the traditional technique). The septum is not sutured. sion with reference to the orbital septum in the preseptal approach
This approach is the best in young women with lipodys-
trophy, with fat deposits localized at a higher position. The
preseptal access allows, according to the indications, the fat orbicularis oculi muscle and the orbital septum. The incision
repositioning beyond the orbital border similar to what is is performed 4 mm below the inferior border of the tarsus or,
performed in the traditional blepharoplasty. anyway, halfway between the fornix and the inferior border
of the tarsus (Fig. 3). An excessively low incision should be
avoided for the risk of developing synechiae of the fornix.
3.4 Retroseptal Access Once the capsulopalpebral fascia is cut, a direct access to the
three fat bags is obtained preserving the integrity of the sep-
This is the standard approach that is used in lower transcon- tum and the orbicularis oculi muscle. After performing a
junctival blepharoplasty and it is definitely the preferred one medial opening, the medial bag emerges immediately
for fat removal using the transconjunctival access. This (Fig. 4). Tractions on the adipose tissue should be avoided,
approach allows the direct access to the palpebral bags, preventing its bleeding. It is advisable to start with the
keeping the orbital septum intact. This results in the most removal of the medial bag in order to facilitate the exposition
direct route to the fat bags preserving the integrity of both the and the removal of the central one. It is important to identify
776
Fig. 3 Schematic drawing showing the level of the conjunctival inci-
sion with reference to the orbital septum in the retroseptal approach
Fig. 4 Schematic drawing showing, during the retroseptal approach, the
herniation of the adipose tissue from the medial bag after the incision of
its capsule. The arrow shows the position of the inferior oblique muscle
the inferior oblique muscle that is used as a land mark for the
removal of the central fat bag, located laterally and distally to
the muscle (Fig. 5).
The fat bags are gently resected protecting the inferior
oblique muscle.
The lateral bag is exposed by a lateral incision, keeping a
central fascia of inferior retractors, which is important to
maintain the palpebral stability. This aims to avoid altera-
tions of the lid position such as the entropion.
N. Scuderi and L.A. Dessy
Fig. 5 Schematic drawing showing, during the retroseptal approach,
the herniation of the adipose tissue from the medial bag after the inci-
sion of its capsule. This bag is located laterally and inferiorly to the
inferior oblique muscle
During the transconjunctival blepharoplasty, an impor-
tant aspect is to obtain an adequate resection of the fat
bags. The lateral compartment consisting of less dense
and lower quantity of adipose tissue, compared to the oth-
ers, is the most easily resected in defect. In fact, it is cov-
ered by the arcuate fascia, expansion of the oblique
muscle, adjacent to the Loskwood ligament. This fascia
should be incised to remove the bag. In theory, the quan-
tity of fat to remove is that exceeding the inferior orbital
border when the globe is subject to a light pressure. In
secondary blepharoplasties, large residual lateral bags are
usually observed.
An attentive control of the haemostasis is indispensable
before removing the retractor, the traction points and the cor-
neal protector. Then, the irrigation of the conjunctival sac
with saline solution is performed.
Usually, the suture of the conjunctival incision is not per-
formed even if it is suggested by some authors; in this case a
continuous intraconjunctival or transcutaneous suture is per-
formed. The suture allows to reposition, apart from the con-
junctiva, also the retractor muscles, whose discontinuity can
lead, in the postoperative period, to a modest and temporary
dysfunction that appears as the incapacity of the lower lid to
go down during the down gaze.
3.5 Skin Treatment
After the removal of the fat bags with the transconjunctival
approach, it is sometimes necessary to proceed to the treat-
ment of possible skin excess.
Blepharoplasty: Minimally Invasive Approach
The skin can be removed directly with the pinch tech-
nique or, in cases of major laxity, by sculpting and removing
an only cutaneous flap. A classic subciliary incision is per-
formed along with the dissection of a small skin flap keeping
the orbicularis muscle intact.
In these cases, a canthopexy with orbicularis muscle sus-
pension can be performed. The inferolateral portion of the
pretarsal orbicularis muscle is fixed to the lateral orbital peri-
osteum, slightly higher than the medial canthus. According
to the visible lid flaccidity, other types of canthopexy or can-
thoplasty can be performed. After the canthopexy, the skin
excess is conservatively resected and a continuous suture is
performed.
The superficial fine lines of the lower lid can be signifi-
cantly improved with ancillary treatments such as laser
resurfacing, dermal filler injection and chemical peeling.
3.6 Complications
Complications after transconjunctival lower blepharoplasty
are less frequent compared to the traditional access. The most
frequent one, although it is a technical error rather than a real
complication, is the insufficient removal of adipose tissue at
the lateral compartment of the lower lid. As previously men-
tioned, a lamina of fibrous tissue surrounds the lateral bag;
this fascia should be incised to access the fat. Not very fre-
quent is, instead, the excessive fat removal, which correction
can require the use of dermoadipose grafts or lipofilling.
The lower lid retraction is less frequent than with the tradi-
tional transcutaneous approach because there is no skin removal
and the septum is not damaged during the procedure.
The damage of the inferior oblique muscle is less com-
mon, although a transient weakness of the muscle itself can
be observed.
Another possible complication is the formation of pyo-
genic granulomas. A possible cause for this complication,
although not demonstrated, is the presence of sutures used to
close the conjunctiva. Actually, this event occurred even in
cases where no conjunctival suture was used. The most plau-
sible hypothesis is that the granuloma derives from a chronic
irritation causing an abnormal growth of granulation tissue.
The prevention consists of avoiding adipose tissue remains
from protruding into the wound during the healing process
delaying the process itself.
In patients with loose palpebral tissues, a temporary lid
retraction with subsequent ocular dryness has been noticed.
This reaction seems subsequent to the oedema and therefore
possible to be solved after its disappearance.
The ecchymosis is to be considered a common conse-
quence, while the conjunctival chemosis is the possible reac-
tion to drugs that are locally administered in the postoperative
period.
777
4 Laser-Assisted Transconjunctival
Blepharoplasty
In 1988, David described the use of CO2 laser associated to
transconjunctival blepharoplasty [15].
In general, the use of laser associated to transconjunctival
lower blepharoplasty results in a minor postoperative red-
dening, minor swelling, less pain and discomfort.
Every time a laser source is used, it is necessary that both
the patient and the surgeon wear the appropriate protective
devices. In this specific case, the patient should wear ocular
protectors during the laser treatment in order to prevent dam-
ages to the tissues and especially to the retina.
The laser itself can be used to perform the incision during
the surgical procedure of transconjunctival blepharoplasty
and to perform the laser resurfacing [16]. For the incisional
surgery, it is necessary to use a small spot in order to obtain
a precise cut with a higher power per unit area. A spot size of
0.2–0.4 mm is ideal for the cut at 7–8 W power in standard
continuous-wave mode. The surgeon can modify the amount
of energy emitted by focusing or defocusing the laser spot.
By working at the exact distance or focal point of the laser,
the surgeon can use the maximum energy and the maximum
vaporization with a minimal or peripheral thermic damage to
the surrounding tissues. Conversely, the surgeon can defocus
the laser ray by furthering the handle or increasing the dis-
tance from the target tissue, by diminishing the ability to cut
but increasing the thermic or coagulative activity of the laser.
In the latter case, it is used for the haemostasis or the ablative
resurfacing of the tissues.
Incisional blepharoplasty should always be completed
before starting the laser resurfacing. The eyelid area can be
divided in pretarsal, preseptal and orbital orbicularis regions.
Each region varies in thickness, the pretarsal skin being thin-
ner and gradually increasing towards the orbit and the cheek.
The use of more than two passes is rare. The area around the
lacrimal dot should not be treated in order to prevent its
ectropion. After each pass of laser resurfacing, the skin
should be kept tense in order to obtain a homogeneous pass
of the laser. The areas with deep wrinkles, furrows and ridges
can be selectively pretreated before the two confluent passes
in order to obtain a final more uniform effect. It is important
to vigorously remove the ablated debris between each pass
with a saline solution impregnated gauze, as this enhances
the ablative effect.
The depth of penetration is evaluated according to tis-
sue colour differentiation. In general, the first pass allows
the removal of the epidermal layer obtaining a pink and
erythematous skin. The second pass exposes the papillary
dermis that appears with an orange-like tinge and yellow-
orange shades. A possible third pass allows for entrance
into the reticular dermis that appears yellow-white. This
should be a definite end point to the treatment because
778
further penetration into deeper dermis with a white and
greyish appearance may result in coagulative necrosis
stimulating healing by secondary intention and subsequent
scarring.
Recovery time after laser resurfacing depends on the
type of laser that has been used. With the first CO2 lasers
available, it may require 6 to 12 weeks because of the pres-
ence of persistent oedema. The introduction of the erbium-
YAG and fractional lasers decreased recovery time as well
as the duration of postoperative erythema (Figs. 6, 7, 8, and
9) [17].
Postoperatively, the treated area is extensively irrigated
with saline solution. The area is covered with an occlusive
dry dressing that is left in place for 3–4 days in order to allow
a fast epithelialization. Alternatively, an open dressing can
be performed by covering the treated area with vaseline oil
twice a day until complete epithelialization occurs, usually
within seven days.
4.1 Postoperative Recovery
Postoperative recovery is very short because there is no
external incision. It implies, similar to the traditional
blepharoplasty, the head-elevated position and the applica-
tion of ice during the first 48 h. It is advisable to use spe-
cific ocular collyrium and refreshing pads for several days.
The reddening and swelling are rare during the first post-
operative week.
Fig. 6 Clinical case showing the preoperative (above) and postoperative (below) aspects 2 years after surgery in the frontal (left) and upward
(right) gaze in a patient that underwent a transconjunctival blepharoplasty and erbium-YAG laser resurfacing of the eyelid
N. Scuderi and L.A. Dessy
5 Transconjunctival Upper
Blepharoplasty
The recognition of the limits of transcutaneous blepharo-
plasty for the correction of lower eyelid fine lines leads to a
progressive diffusion of the transconjunctival approach in
combination with chemical peeling or laser resurfacing.
Traditionally, also the upper lid blepharoplasty consists of a
transcutaneous approach that allows the removal of the skin
excess with a well-hidden scar. However, also this approach,
although more rarely, can lead to complications such as lid
retraction, lagophtalmos, or an operated-eye appearance
[18]. The CO2 laser resurfacing can be an alternative to the
skin excision also for the upper eyelid, especially in associa-
tion with an endoscopic forehead lift. However, these alter-
native procedures do not allow the correction of a possible
herniation of the fat bags. In selected cases, the reduction of
fat bags, especially the medial ones, can be performed with a
transconjunctival upper approach.
The transconjunctival upper blepharoplasty has very pre-
cise and restricted indications. The ideal candidate presents a
medial adipose bag without or with an extremely scarce skin
excess. Another indication is the correction of a medial
residual adipose excess to be addressed during a secondary
blepharoplasty. Another indication is the eyebrow ptosis
that, after a forehead lift, develops a medial pseudohernia-
tion without residual skin excess.
Contraindications to transconjunctival upper blepharo-
plasty are upper eyelid skin excess, very low tarsal fold indi-
cating a dehiscence of the pretarsal fascia or the aponeurotic
Blepharoplasty: Minimally Invasive Approach 779

Fig. 7 Clinical case showing the

detail of the preoperative (left)
and postoperative (right) aspects
1 year after surgery in a patient
that underwent a CO2 laser
resurfacing of the eyelid

Fig. 8 Clinical case showing the preoperative (above) and postoperative

(below) aspects 1 year after surgery in a patient that underwent transcon-
junctival blepharoplasty and CO2 laser resurfacing of the eyelid

Fig. 9 Clinical case showing the preoperative (above) and postopera-

insertion, and the presence of adipose excess in the central
tive (below) aspects 1 year after surgery in a patient that underwent
and lateral bags. transconjunctival blepharoplasty and CO2 laser resurfacing of the
eyelid

5.1 Anatomy and Surgical Technique [19–21]

As for the lower eyelid transconjunctival approach, a precise
knowledge of the anatomical structures is of utmost impor-
tance. The division in anterior (skin and orbicularis oculi mus-
cle) and posterior (tarsus and conjunctiva) lamella appears too
simplistic and misleading. It is better to divide the upper eyelid
in a tarsal and orbicularis portion, marking as a limit the supra-
tarsal fold, which is formed by the insertion of the levator apo-
neurosis, orbital septum and suborbicularis fascia on the deep
surface of the orbicularis oculi muscle. The fold is located
780 N. Scuderi and L.A. Dessy

around 3 mm above the tarsus in Caucasians and lower in
Asians (Fig. 10). The fusion of these structures acts like a sep-
tum on the periorbital fat. It is important to notice that the level
of this septum is lower laterally and higher medially (Fig. 11).
Above the supratarsal fold, or in the orbicularis portion of the
eyelid, the levator aponeurosis is separated from the orbital
septum by the periorbital fat. On the upper eyelid it is possible
to identify at least two fat bags (medial and central), but an
accessory lateral bag is identifiable in more than 20 % of
patients (Fig. 12) [22, 23]. The medial adipose bag is pale yel-
low or white and it is located medial to the levator aponeurosis
and at the root of the nose (Figs. 11 and 12). Histologically, it
presents a larger quantity of connective tissue, vascularization
and sensitive innervation from the supratrochlear nerve. The
sal margin. The incision should extend for no more than
8 mm. Then, scissor dissection is performed directing
towards the contralateral parietal bone. Such dissection
allows to easily pierce the thin layer of connective tissue and
to make the medial fat bag easily accessible through the con-
junctival incision. The damage of the medial horn of the
levator palpebrae muscle as well as the trochlea that is
located in the medial portion of the orbit superoposteriorly to
the dissecting area should be avoided. The fat is then clamped
Central fat pad
Fusion line of
the fascia and
and pre
aponeurotica
orbital septum

central and lateral bags have a bright yellow colour and are Medial fat pad
Lacrimal
located above the levator aponeurosis. gland
The operation can be performed under local or general Lacrimal sac Levator aponeurosis
(which is part of the
anaesthesia. A topical anaesthesia of the eye globe is per- tarsal plate)
formed before the placement of the corneal protector, fol-
lowed by local anaesthesia with epinephrine both on the skin
and the conjunctiva.
The area is then exposed with the appropriate retractor so
as to incise the conjunctiva medially, 3–4 mm above the tar-

Medial, central and lateral

fat pads of the lower eyelid

Fig. 11 Schematic drawing showing the position of the eyelid fat bags

Orbicularis
oculi m.
Orbital septum
Lateral extension of
pre aponeurotica
Orbital Nasal fat pad Central fat pad fat
fat (orbital fat) Lacrimal
gland
Levator Muscle of Muller
aponeurosis

Conjunctiva
Tarsal plate

Orbicularis oculi muscle

Fig. 10 Schematic drawing showing the division of the upper eyelid in
tarsal and orbicularis portion on the supratarsal fold, which consists of Fig. 12 Schematic drawing showing the position of the accessory lat-
the levator aponeurosis, orbital septum and deep fascia of the orbicu- eral bag (identifiable in more than 20 % of patients) and its relationship
laris oculi muscle with the lacrimal gland
Blepharoplasty: Minimally Invasive Approach
and excised after the precautional coagulation of its pedicle.
The quantity of fat to be removed depends on what protrudes
from the incision and what is visible when gently pushing
the eye globe. It is not usually necessary to suture the con-
junctival margins. The postoperative care is similar to the
lower eyelid transconjunctival approach.
Conclusions
The better knowledge of the oculo-palpebral anatomy along
with the need to minimize the undesired effects of tradi-
tional blepharoplasty led to the development of minimally
invasive surgical techniques, i.e. the transconjunctival
blepharoplasty for the lower and upper eyelid, allowing to
reduce the risk of lid retraction with subsequent scleral show
and ectropion. Moreover, the skin removal, main cause of
the retraction, is often unable to correct the fine lines.
Usually the expert surgeon, that is able to perform both
the transcutaneous and transconjunctival blepharoplasty,
evaluates the presence or absence of skin excess as the
decisive factor in the choice for the most appropriate
method in the specific case. The transconjunctival
approach is usually for cases without skin excess. On the
contrary, but only in lower blepharoplasty, some authors
believe that the procedure is indicated every time there is
adipose excess. In case a skin excess is also present, this
is removed by sculpting a skin flap or by using the pinch
technique. In these cases, it is often recommended a can-
thoplasty or canthopexy. Recently, the tendency is to con-
sider the skin excess as relative, since a certain quantity of
skin is necessary to cover the remaining area after the fat
bag removal. As a consequence, always more conserva-
tive skin resections are performed.
It is also necessary to remind the benefits that can be
obtained on periocular skin with chemical peelings or
laser resurfacing, which can be performed simultaneously
to the surgical transconjunctival treatment or after it. These
procedures are able to effectively reduce the periocular
fine lines and, even if to a lesser extent, the skin laxity.
In conclusion, the transconjunctival blepharoplasty is
an easily performed surgical procedure that does not leave
visible scars and respects the functional integrity of the
anatomical structures and the active support of the eyelid.
The transconjunctival blepharoplasty appears an elegant
and safe technique both for young people avoiding exter-
nal scars and for elder people preventing the development
of scleral show and ectropion, which are possible compli-
cations of the traditional approach.
781
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 Lateral Canthal Surgery
in Blepharoplasty
Glenn W. Jelks and Elizabeth B. Jelks
The development of lateral canthal surgical procedures par-
allels the understanding and treatment of lower eyelid mal-
positions caused by congenital or acquired conditions.
Protection of the eyes with preservation of vision is the ratio-
nale for lateral canthal procedures. Lateral canthal proce-
dures are designed to manage existing lower eyelid
malpositions. They are surgical techniques employed at the
time of blepharoplasty to prevent lower eyelid malpositions.
This discussion describes the evolution of modifications
of lateral canthal procedures that have been used to manage
lower eyelid malpositions resulting from (1) cicatricial,
atonic, or paralytic lower eyelid malpositions; (2) lateral can-
thal dystopia (lateral canthus lower than the medial canthus);
(3) lacrimal disorders; (4) loss of tissue due to trauma or
tumor resection; (5) post-traumatic orbital deformities; and
(6) craniofacial deformities and other syndromal anomalies.
The concomitant use of autogenous auricular cartilage or
palatal mucosa lower eyelid vertical spacer grafts, bone
anchors for suspension of the midface, myocutaneous flaps,
skin grafts, and mucosal grafts allows reliable reconstruction
of lower eyelid malpositions. Lateral canthal procedures can
have a direct or indirect effect on the functional anatomy of
the lateral aspects of the upper and lower eyelids as they
interrelate with the lateral retinaculum. Direct lateral canthal
procedures reconstruct the anatomical elements of the lateral
retinaculum and are designed to establish normal protective
eyelid function. Indirect lateral canthal procedures support
the midface, cheek, temporal area, and brows. These ancil-
lary procedures are very effective in reconstruction of com-
plex lower eyelid malpositions [1, 3, 17, 19, 21].
Von Walther designed the simple lateral tarsorrhaphy pro-
cedure to correct the upper and lower eyelids laterally. This
G.W. Jelks, MS, MD, FACS (*)
Ophthalmology and Plastic Surgery, New York University Langone
Medical Center, New York, NY, USA
e-mail: gwj@jelksmedical.com
E.B. Jelks, MD
Private Practice, Jelks Medical, New York, NY, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_56
had the disadvantage of distorting the lid margins and
decreasing the functional fields of vision. McLaughlin
described a lateral tarsorrhaphy procedure that produces a
more aesthetic result for non-cicatricial, paralytic lower eye-
lid malposition with lagophthalmos [13].
Lateral canthorrhaphies were developed to avoid the defor-
mities associated with the tarsorrhaphies. These procedures
were various flap transpositions with skin removal to support
the lower eyelid to the upper eyelid at the lateral canthus.
Denonvilliers, Kuhnt-Szymanowsk, and Meller described pro-
cedures which were widely accepted. Modifications of these
procedures were described by Smith and Kazanjian and
Converse with a tarsoconjunctival wedge excised medially.
Bick reported a technique removing the full thickness tempo-
ral aspect of the lower eyelid to correct laxity [13].
Edgerton and Wolfort [2] described a de-epithelialized
dermal pennant of lateral canthal tissue that was passed
through a drill hole in the lateral orbital wall to correct lower
eyelid malposition (Fig. 1a, b). Montandon [7] modified this
procedure to include a lateral tarsorrhaphy (Fig. 1c). Rees [4]
described horizontal lid shortening (HLS) techniques at the
lateral canthus from the blepharoplasty approach. Lateral
canthal suspensions have also been described via facelift
incision access to the lateral orbital rim by Whitaker [14].
Ortiz-Monasterio and Rodriguez [15] described upper and
lower canthal fixation from the coronal approach in craniofa-
cial and cosmetic surgical interventions. Paterson, Munro,
and Farkas described lateral canthal fixation via the conjunc-
tival approach [16].
Jelks [3, 11, 13, 22], Hinderer [20], and Flowers [18]
described variations in bone or periosteal fixation of the lat-
eral canthal portion of the lower eyelid.
Many surgeons developed their own methods of creating the
lateral canthal angle by various suture techniques. The most
effective methods isolate the lower lid contribution to the lateral
retinaculum by a lateral canthotomy and cantholysis of the infe-
rior limb of the lateral canthus at the bony orbital rim. The lower
eyelid is thus released from the upper eyelid and retinacular
structures to allow more selective repositioning (Fig. 2a).
783
784
a b
Flame shaped flap
De-epithialization
Fig. 1 (a) De-epithelized dermal-orbicularis oculi muscle pennant of
tissue is elevated lateral to the commissure. Note there is no decrease in
horizontal palpebral aperture. (b) The pennant is passed through a large
fenestration in the lateral orbital bone. Note there is no decrease in pal-
Fig. 2 Variations in lateral canthal procedures that selectively separate
the lower eyelid from the upper eyelid (lateral canthotomy) and from the
lateral retinaculum attachments (inferior lower lid retinacular cantholy-
sis). Removal of epithelial elements from the lateral lower eyelid
creates a strip of tarsus corresponding to the amount of horizontal lid
G.W. Jelks and E.B. Jelks
c
pebral aperture (Egerton 1969). (c) The pennant passed through lateral
orbital bone fenestration and shortening of palpebral aperture with lat-
eral tarsorrhaphy [7] (From Jelks and Smith [13], p. 1719)
shortening. (a) Tarsal Strip procedure. (b) Tarsal strip passed through
upper eyelid lateral canthal structure [6]. (c) Tarsal strip passed under
medial-based periosteal flap (Martsh 1979). (d) Tarsal strip passed
under laterally based periosteal flap (Baylis and Hamako 1980) (From
Jelks and Smith [13], pp 1720–1721)
Lateral Canthal Surgery in Blepharoplasty
Anderson and Gordy [9], Jordan and Anderson [12],
Lisman et al. [5], Jelks et al. [22], Patipa [26, 27], McCord
[28, 35], Fagien [29], Codner [30–33], and Hester [34, 36]
have described various methods of tarsal and or inferior reti-
nacular attachment to the bony orbital tissues that selectively
tighten and reposition the lower eyelid. Tenzel [6] described
a lateral canthoplasty which passed through the upper lateral
canthal retinacular structures to better approximate the lower
lid to the globe (Fig. 2b). Marsh and Edgerton [8] (Fig. 2c)
and Hamako and Baylis [10] (Fig. 2d) described periosteal
flaps to fixate the lower lid to the bony orbital rim. Bachelor
and Jobe, Holt, Holt and van Kirk, and Leone described the
use of periosteal flaps and temporalis fascia and palmaris
longus tendons for lateral canthal reconstructions [13].
Lateral canthal procedures are designed to provide effec-
tive lower eyelid tightening and lateral canthal elevation
effects.
1 Anatomy
To facilitate a thorough anatomical analysis, the eyelids and
surrounding structures are divided into zones (Fig. 3).
Zone I is the upper eyelid which extends from the lid mar-
gin to the superior orbital bone margin. It is a layered ana-
tomical structure best described to be consisting of three
layers or lamellae. The anterior lamella (AL) is composed of
skin and underlying orbicularis oculi muscle. The middle
lamella (ML) is composed of the tarsus, orbital septum, ret-
roseptal fat, levator superioris aponeurosis, and the origin of
Mueller muscle. The posterior lamella (PL) is composed of
conjunctiva and portions of Mueller muscle. The middle
lamella of the upper eyelid contains the levator muscle and
Mueller muscle structures that elevate the upper eyelid.
Zone II is the lower eyelid and extends from the lid mar-
gin to the inferior orbital bony rim and is separated into the
anterior lamella (AL) of skin and orbicularis oculi muscle;
the middle lamella (ML) consisting of tarsus, orbital septum,
and retroseptal fat; and the posterior lamella (PL) with the
capsulopalpebral fascia or lower eyelid retractors and the
conjunctiva (Fig. 4a).
The confluence of the orbital septum, orbital floor perior-
bita, and maxillary periosteum at the inferior bony margin is
termed the arcus marginalis (Fig. 4b). The arcus marginalis
in the inferior medial orbit corresponds to the origin of the
orbital portion of the orbicularis oculi muscle (Fig. 4c). The
orbicularis oculi muscle originates from the medial orbit to
cover significant portions of the facial muscles of expression
(Fig. 4d) [25].
The orbicularis oculi muscle is innervated by the seventh
cranial nerve and acts as an antagonist to the levator palpe-
brae superioris muscle innervated by the third cranial nerve.
The orbicularis oculi muscle is divided into palpebral and
785
Fig. 3 Surgical zones of the eyelids and periocular structures: Zone 0
(not labeled) includes the ocular globe and orbital structures behind the
orbital septum, orbital retaining ligaments, arcus marginalis, posterior
lacrimal crest, and lateral retinaculum. Zones I and II include the upper
and lower eyelids, respectively, from the lateral commissure to the can-
alicular puncti. Zone III is the medial canthus with the upper and lower
eyelid lacrimal drainage system. Zone IV is the lateral canthal area with
the lateral retinaculum. Zone V includes the contiguous periorbital
structures of nasal, glabellar, brow, forehead, temple, malar, and naso-
jugal regions that merge with Zones I–IV. Zones I–IV are further subdi-
vided into structures that are anterior (preseptal) and posterior
(postseptal) to the orbital septum (From Spinelli and Jelks [24])
orbital portions. The palpebral portion is further subdivided
into pretarsal and preseptal portions. The orbital portion of
the orbicularis oculi arises medially from the superiormedial
orbital margin, the maxillary process of the frontal bone, the
medial canthal tendon, the frontal process of the maxilla, and
the inferiormedial orbital margin (Fig. 4c).
The peripheral fibers sweep across the eyelid over the
orbital margin in a series of concentric loops, the more cen-
tral ones forming almost complete rings. In the lower eyelid,
the orbital portion covers the origins of the elevator muscles
of the upper lip and nasal ala and continues temporally to
cover part of the origin of the masseter muscle. Occasionally,
the lower orbital portion may actually continue as low as the
corner of the mouth. The inferior orbital orbicularis oculi
constitutes the nasojugal, cheek, and malar area of the facial
anatomy (Fig. 4d).
The preseptal portion diverges from its origin on the
medial canthal tendon and posterior lacrimal diaphragm and
passes across the lid as a series of half ellipses to meet at the
lateral palpebral raphe (Fig. 5a). The muscle bundles are not
interrupted and do not interdigitate at the raphe. The lateral
canthal tarsoligamentous structures are formed from the
lateral portions of the upper and lower eyelid tarsi with
contributions from the pretarsal orbicularis oculi muscles.
Therefore, the lateral canthal structures can be called both
a ligament and a tendon. The more superficial portion is
786
Fig. 4 (a) Zone II, the lower eyelid is best represented anatomically as
consisting of three lamellae. The anterior lamella (AL) is composed by
the skin and orbicularis oculi muscle. The posterior lamella (PL) is the
conjunctiva and the capsulopalpebral fascia, an extension of the fascia
surrounding the inferior rectus muscle. The middle lamella (ML) is
composed of the orbital septum and fat which abuts the inferior border
of the tarsus. (b) The arcus marginalis is formed by the fusion between
the periorbita, periosteum, and orbital septum. (c) The green outline
tendinous and the posterior portions are ligamentous. The
pretarsal muscles form the more superficial common lateral
canthal tendon 7 mm from the lateral orbital tubercle where
it inserts (Fig. 5b).
The medial canthus (Zone III) is a complex region con-
taining the origins of the orbicularis oculi muscle and the
lacrimal collecting system.
Zone IV is the lateral canthus which is an integral ana-
tomic unit of the temporal aspects of the upper and lower
eyelids [1] (Fig. 6). The lateral canthus is more correctly
termed a lateral retinaculum which consists of the lateral
G.W. Jelks and E.B. Jelks
denotes the medial bony origins of the orbicularis oculi muscle. The
orbital septum attaches to the orbital margin at a thickening called the
arcus marginalis (black arrows). The arcus marginalis often forms the
inferior part of the supraorbital groove (*). The arcus marginalis is also
closely associated with the orbital retaining ligaments, orbital perior-
bita, and the facial bone periorbita. (d) Extent of the orbicularis oculi
muscle and its relationship to the muscles of facial expression [37]
horn of the levator palpebrae superioris muscle, the continu-
ation of the preseptal and pretarsal orbicularis oculi muscle
as the lateral canthal tendon and associated tarsoligamentous
structures, the inferior suspensory ligament of the globe
(Lockwood’s ligament) and the check ligaments of the lat-
eral rectus muscle. The lateral retinaculum structural
components attach to a confluent region of the lateral orbital
rim known as Whitnall’s tubercle. It is important to note that
the lower eyelid lateral fat is immediately inferior to the
lower eyelid contribution to the lateral canthal tendon and
associated tarsoligamentous structures inserting into the
Lateral Canthal Surgery in Blepharoplasty
Fig. 5 (a) The preseptal orbicularis oculi muscle originating from pos-
terior lacrimal creas and the medial canthal tendon (T) passes across the
eyelid to meet at the lateral palpebral raphe (PR). (b) The lateral canthal
tarsoligamentous structure inserts into the lateral orbital tubercle (*)
which has been elevated from the lateral orbital rim periosteum [37]
orbital tubercle confluence termed the lateral retinaculum.
This portion of the lateral canthal mechanism is termed the
inferior retinacular component and is the anatomical basis
for the inferior retinacular lateral canthoplasty (IRLC) [22].
Zone V includes the contiguous periorbital structures of
the nasal, glabellar, brow, forehead, temple, malar, zygo-
matic, and nasojugal regions that merge with Zones I–IV.
It is often difficult to determine which lateral canthal pro-
cedure to utilize. In order to justify the most appropriate lat-
eral canthal procedure, it is necessary to obtain a complete
general and ocular history, determine the precise chief com-
plaint and document pertinent physical findings. The physi-
cal examination should include the best corrected visual
acuity of each eye. The inability to completely close the
eyelids (lagophthalmos) and the absence of ocular globe
elevation with eyelid closure (Bell’s phenomenon) are
very important to document since they influence the type of
787
Fig. 6 The lateral canthus is really a lateral retinaculum composed of
several structures which converge at the orbital tubercle of Whitnall
(arrow). The lateral retinacular structures which insert into the orbital
tubercle are the lateral horn of the levator muscle with its aponeurosis,
the lateral canthal tendon and tarsoligamentous structures, the inferior
suspensory ligament of the globe (Lockwood), and the check ligament
of the lateral rectus muscle. The lateral extension or horn of the levator
muscle aponeurosis (forceps) splits the lacrimal gland into its orbital
(O) and palpebral (P) lobes and extends inferiorlaterally to join the lat-
eral retinaculum. Whitnall’s ligament (W) is the superior suspensory
ligament of the levator palpebrae superioris muscle (From Jelks and
Smith [13], p 1671) [37]
lateral canthal procedure that is utilized. Magnified
evaluation of the cornea with fluorescein dye is performed
to determine any staining of the cornea due to exposure or
faulty eyelid closure. Tear breakup time is performed to
evaluate the quality of the tear film. The tear breakup time is
performed by placing a topical ophthalmic anesthetic solu-
tion and fluorescein dye on the corneal surface and observ-
ing the first visible tear film dispersion with the eyelids held
open. Normal tear breakup time is 8–10 s. Tear breakup
time less than 6 s is considered abnormal and indicates the
presence of tear film imbalance. This can produce signifi-
cant ocular exposure symptoms following eyelid surgery.
The palpebral apertures are evaluated for the presence of
upper eyelid ptosis or retraction. The position of the upper
eyelid level is measured in relation to the midposition of the
pupil with the eyes in primary gaze. Each upper eyelid level
is documented as the number of millimeters displaced from
the midpupil level while preventing frontalis muscle contrac-
tion. True ptosis caused by levator muscle abnormalities
should be distinguished from lash ptosis which is caused by
mechanical upper eyelid descent from heavy upper eyelid
tissue. The presence of upper eyelid retraction often occurs
with thyroid ophthalmopathy. If upper eyelid retraction is
present, the thyroid function should be tested.
The lower eyelid levels are measured in relation to the
position of the inferior corneal limbal position with the eyes
788
in primary gaze. The amount of sclera showing inferior to the
inferior corneal limbus is documented in millimeters.
Alternatively, the amount of scleral triangles exposed from
the medial and lateral palpebral apertures can be measured
from photographs. The presence of lower eyelid mid lamel-
lar restriction is determined by the vertical lower eyelid dis-
traction test. The vertical distraction test is performed by
pushing the lower eyelid margin in the direction of the pupil
and measuring the lower lid margin level in relation to the
position of the pupil in primary gaze. The lower eyelid
should be able to be vertically distracted to a level above the
pupil. Restriction of vertical lower eyelid movement is a
positive vertical distraction test and indicates mid lamellar
vertical contraction, cicatrix, or adhesions. The use of verti-
cal spacer grafts is often required in lower eyelid reconstruc-
tions with positive vertical distraction tests.
The horizontal position of the medial canthus to the hori-
zontal position of the lateral canthus with the eyes in primary
gaze is documented in all patients. When the lateral canthus
is lower than the medial canthus, there is a “negative” can-
thal tilt. A “positive” canthal tilt is present when the lateral
canthus position is higher than the medial canthus. Canthal
tilt is measured because certain lateral canthal procedures
cannot be used with a “negative” canthal tilt (lateral canthal
position inferior to the medial canthal position).
The important variations in individual anatomy include
brow position; frontalis, corrugator, depressor superciliae,
procerous spasms; glabellar, nasal, lateral orbital furrows;
malar pads; festoons; nasojugal tear trough deformity; fat
protrusion; and midfacial descent. Particular attention to the
documentation of these variations in anatomic morphology
is important and is helpful in selecting the most appropriate
lateral canthal procedure.
Vector analysis is performed in all patients. Vector analysis
measures the relative position of the cheek soft tissue volume
and malar bony prominence to the position of the ocular globe.
Vector analysis is performed by determining the most anterior
projection of the maxillary bony and soft tissue prominence to
the most anterior projection of the lower eyelid and the most
anterior projection of the ocular globe. A positive vector is
when the maxillary prominence is anterior to the lower lid and
globe position (enophthalmos, maxillary bone advancement).
A negative vector is when the globe and lower eyelid are more
anterior than the underlying maxillary prominence (Fig. 7).
Positive, neutral, and negative vector relationships occur in
normal individuals. Negative vector relationships also occur
with exophthalmos, high myopia, maxillary hypoplasia, and
thyroid orbitopathy. Positive vector relationships occur with
enophthalmos and maxillary bony advancement [23].
The presence of horizontal lid laxity is determined by per-
forming the lower eyelid distraction and snap test. The dis-
traction test is performed by gently pinching the lower eyelid
with the thumb and index finger and distracting it horizontally
G.W. Jelks and E.B. Jelks
from its contact with the globe. A distraction of more than
8 mm is considered a positive test for the presence of horizon-
tal lid laxity. The snap test is performed by gently distracting
the lower eyelid horizontally and inferiorly from contact with
the globe. The eyelid is released and a snap back of the lower
eyelid to regain contact with the globe is observed. Absence
of the “snap” indicates poor tarsoligamentous support and
corroborates the presence of horizontal lid laxity.
Horizontal lower eyelid laxity is often associated with medial
canthal laxity, lower eyelid margin eversion, or frank ectropion
or entropion. Occasionally the posterior lamella of conjunctiva
can have scarring, inflammation, or lesions. All of these factors
influence which lateral canthal procedure is appropriate.
The essential physical findings to identify in a patient
requiring a lateral canthal procedure in conjunction with a
primary blepharoplasty or with a secondary reconstructive
blepharoplasty are listed in (Table 1) and illustrated in Fig. 7.
Careful evaluation of the specific anatomic deformities
enables the surgeon to choose the optimal lateral canthal pro-
cedure and if necessary, ancillary procedures (Tables 2 and 3).
1.1 Summary
The distance from the lateral palpebral commissure to the
bony orbital rim is the single most important measurement
in choosing between a canthopexy, canthoplasty, or dermal
orbicular pennant lateral canthoplasty (DOPLC) (Fig. 7c). If
the bone to soft tissue distance is less than 1 cm, a horizontal
wedge resection performed in the lateral lower eyelid, tarsal
strip, inferior retinacular lateral canthopexy (IRLCx) or
inferior retinacular lateral canthoplasty (IRLC) procedures
are preferred. If the distance is greater than 1 cm (prominent
globes, high myopia, thyroid orbitopathy, malar hypoplasia,
and negative vector relationship), a dermal orbicular pen-
nant lateral canthoplasty is recommended. When the diagno-
Table 1 Physical findings for determining lateral canthal procedures
1. Palpebral apertures (scleral show, asymmetry)
2. Vector analysis (negative, neutral, or positive)
3. Horizontal lid laxity (distraction, snap test, lid margin
eversion, ectropion, entropion)
4. Soft tissue to bone distance greater than or less than 1 cm
(exophthalmos, prominent globes, high myopia, orbital bone
deformities, morphology)
5. Canthal tilt (orbital dystopia, midlamellar cicatrix, anterior
lamellar deficiency, posterior lamellar deficiency, midfacial
decent, post-traumatic facial deformity)
6. Midlamellar vertical eyelid restriction (vertical retraction
test, positive will need vertical spacer graft)
7. Midfacial descent (orbital dystopia, midlamellar cicatrix,
anterior lamellar deficiency, posterior lamellar deficiency).
Midfacial descent (post traumataic facial deformity) will need
Mitek midfacial suspension
Lateral Canthal Surgery in Blepharoplasty
Fig. 7 (a) Palpebral apertures analysis for scleral show, asymmetry,
lagophthalmos, lid margin eversion, and ectropion. (b) Vector analysis
determines the relative position of the most anterior projection of the
globe, lower eyelid, and malar eminence to each other. A negative vec-
tor relationship is illustrated. (c) Soft tissue to bone distance measures
the distance from the lateral commissure to the lateral bony orbital rim.
A distance greater than 1 cm influences the type of lateral canthoplasty
utilized. (d) Horizontal lid laxity is demonstrated by a lower eyelid dis-
sis of horizontal lid laxity is made with the positive
distraction and snap test of the lower eyelid (Fig. 7d), a hori-
zontal lid shortening procedure is required. However, when
there is a negative canthal tilt (Fig. 7e) and a soft tissue to
bone distance greater than 1 cm, a simple horizontal wedge
resection is contraindicated and lateral canthal procedure
that includes horizontal lid shortening and lateral canthal
elevation must be used.
789
traction test greater than 8 mm documenting tarsoligamentous laxity.
(e) Canthal tilt is negative when the lateral canthus is lower than the
medial canthus. A horizontal wedge resection is contraindicated with a
negative canthal tilt. (f) Mid-lamellar retraction occurs when there is a
vertical restriction of lower eyelid movement due to mid-lamellar cica-
tricial changes. (g) Midfacial descent occurs when the lid cheek-
junction is inferiorly displaced (arrow). Elevation of the mid-face must
be incorporated with lower eyelid procedures
2 Inferior Retinacular Lateral Canthal
Procedure
The inferior retinacular lateral canthopexy (IRLCx) or inferior
retinacular lateral canthoplasty (IRLC) was developed for use
in the primary blepharoplasty patient to help prevent lower
eyelid malposition. It is helpful in correction of lower eyelid
malposition associated with a negative vector relationship and
790 G.W. Jelks and E.B. Jelks

Table 2 Canthoplasty techniques

Technique Indications Physical findings
Inferior retinacular lateral canthopexy (IRLCX) Prevent LLM Mild lid eversion
Cosmetic BLEPH Scleral show 1 mm
Asymmetry Asymmetry lower lids
Negative vector
Inferior retinacular lateral canthoplasty (IRLC) Prevent LLM Moderate lid eversion
Treat LLM Scleral show 1–2 mm
Cosmetic BLEPH Asymmetry lower lids
Asymmetry Negative vector
HLL ≤ 8 mm
Bone-STD < 1 cm or > 1 cm
Horizontal wedge resection at lateral canthus (HWR) Prevent LLM Moderate lid eversion
Treat LLM Scleral show 1–2 mm
Cosmetic BLEPH Asymmetry lower lids
Asymmetry Negative vector
HLL ≤ 8 mm
Bone-STD < 1 cm or > 1 cm
Positive or neutral canthal tilt
Note: HWR contraindicated with negative canthal TILT
Tarsal strip lateral canthoplasty with horizontal Cosmetic BLEPH Moderate lid eversion
lid shortening at lateral canthus (TSLC HLS) Secondary BLEPH Scleral show 1–2 mm ectropion
LLM Asymmetry lower lids
Negative vector
HLL ≥ 8 mm
Bone-STD < 1 cm or > 1 cm
Positive, neutral, or negative canthal tilt
No midlamellar restriction
Tarsal strip lateral canthoplasty with horizontal lid Cosmetic BLEPH Moderate lid eversion
shortening and vertical spacer graft (TSLC HLS VSG) Secondary BLEPH Scleral show 1–2 mm ectropion
LLM Asymmetry lower lids
Negative vector
HLL ≥ 8 mm
Bone-STD < 1 cm or > 1 cm
Positive, neutral, or negative canthal tilt
Midlamellar restriction
Dermal orbicular pennant lateral canthoplasty Cosmetic BLEPH Bone-STD ≤ cm, > 1 cm
no lateral canthotomy (DOPLC) Secondary BLEPH
Dermal orbicular pennant with lateral canthoplasty Cosmetic BLEPH Moderate lid eversion
tarsal strip horizontal lid shortening lateral Secondary BLEPH Scleral show 1–2 mm ectropion
canthoplasty (DOP TS HLS) Asymmetry lower lids
Negative vector
HLL ≥ 8 mm
Bone-STD < 1 cm or > 1 cm
Positive, neutral, or negative canthal tilt
Dermal orbicular pennant with tarsal strip Cosmetic BLEPH Moderate lid eversion
horizontal lid shortening lateral canthoplasty Secondary BLEPH Scleral show 1–2 mm ectropion
with vertical spacer graft (DOP TS HLS VSG) Asymmetry lower lids
Negative vector
HLL ≥ 8 mm
Bone-STD < 1 cm or > 1 cm
Positive, neutral, or negative canthal tilt
Midlamellar restriction
Dermal orbicular pennant with tarsal strip Cosmetic BLEPH Moderate lid eversion
horizontal lid shortening lateral canthoplasty Secondary BLEPH Scleral show 1–2 mm ectropion
with vertical spacer graft and midfacial Asymmetry lower lids
suspension (DOP TS HLS VSG MFS) Negative vector
HLL ≥ 8 mm
Bone-STD < 1 cm or > 1 cm
Positive, neutral, or negative canthal tilt
Midlamellar restriction
Midfacial descent
LLM lower eyelid malposition, BLEPH blepharoplasty, HLL horizontal lid laxity, HLS horizontal lid shortening, Bone-STD bone; to soft tissue
distance, VSG vertical spacer graft, MFS midfacial suspension
Lateral Canthal Surgery in Blepharoplasty
Table 3 Ancillary lower eyelid reconstructive techniques
Technique Indication
Upper eyelid myocutaneous flap to Anterior lamellar deficiency
lower eyelid
Full thickness skin graft to lower eyelid Anterior lamellar deficiency
Buccal mucous membrane graft Posterior lamellar deficiency
Palatal mucous membrane graft Posterior lamellar deficiency
mild-to-moderate lid margin eversion. The main advantage of
the inferior retinacular canthal procedure is that it does not
separate the lower eyelid from the upper eyelid by lateral pal-
pebral commissure cantholysis. Therefore, the horizontal pal-
pebral aperture remains the same. The inferior retinacular
lateral canthal procedure is performed through a horizontal
lateral canthal incision or an upper lateral eyelid crease inci-
sion (Fig. 8a). When an upper lateral eyelid incision is utilized,
a skin and muscle flap is developed in a submuscular and
supraperiosteal plane along the lateral orbital rim extending
onto the lateral aspect of the inferior orbital rim. This exposes
the lower eyelid lateral fat just behind the orbital septum
(Fig. 8a). The inferior aspect of the lateral retinaculum lies
immediately superior to this fat. The lateral fat pad can be
retracted or removed to better expose the inferior portion of
the lateral retinaculum. After manipulation of the lateral lower
lid fat, a cavity is created in the inferior aspect of the dissec-
tion. This resembles a “cave”. The roof of the cave corre-
sponds to the inferior retinacular component of the lateral
canthal retinaculum. This lower eyelid retinacular structure is
lateral to the tarsal tendinous and ligamentous extensions of
the lower eyelid passing to insert into the orbital tubercle of
Whitnall and thus contributing to the lateral retinaculum.
This lower eyelid component of the lateral retinaculum can
be grasped with forceps and sutured to the lateral orbital rim as
an inferior retinacular lateral canthopexy (IRLCx) (Fig. 8b) or
grasped, lysed from the bone insertion, and sutured to an ele-
vated position on the inner aspect of the orbital rim periosteum
as an inferior retinacular lateral canthoplasty (IRLC) (Fig. 8b).
The inferior retinacular lateral canthoplasty procedure
releases the lower eyelid completely from all lateral attach-
ments to the bony orbit and allows free movement of the lower
eyelid due to its direct communication with the inferior reti-
nacular component of lateral retinaculum. Fixation to the inner
aspect of the lateral bony orbital rim periosteum is with a 5-0
Nylon (Ethibond P-3 needle) for aesthetic procedures blepha-
roplasty and with a 4-0 Polydek (Deknatel ME-2 needle) for
secondary blepharoplasty and lower eyelid malposition recon-
structive procedures. The lateral canthoplasty is completed by
tightening the suture and securing the lower lid lateral retinacu-
lum to an elevated position inside the lateral orbital rim.
The lower eyelid level should cover 1–2 mm of the infe-
rior cornea and appear overcorrected. The level of lateral
orbital rim fixation approximates the upper level of the pupil
when in primary gaze (looking straight ahead) (Fig. 8c). The
791
lower eyelid settles into a lower position in 2–6 weeks.
Symmetry of the eyelids at the completion of surgery is
imperative. If the fixation of the lateral retinacular tissue to
the orbital periosteum is inadequate due to scarring or
trauma, a local periosteal flap or fascial graft is used.
Occasionally, a drill hole in the lateral orbital bone may be
required for secure fixation. It should be emphasized that the
main advantage of the inferior retinacular canthal procedure
is that it does not separate the lower eyelid from the upper
eyelid by lateral palpebral commissure cantholysis. The lat-
eral canthal elevation and tightening is obtained without dis-
ruption of the lateral commissure soft tissue connection.
There is less distortion to the lateral commissure and the
horizontal palpebral aperture remains the same (Fig. 9).
3 Horizontal Pentagonal Wedge
Resection in the Lateral Lower
Eyelid (HLS)
When horizontal lid laxity is documented by the snap and
distraction test (Fig. 7d), a horizontal lid shortening with a
full thickness eyelid wedge resection procedure is required
during primary and secondary blepharoplasty (Fig. 10). The
amount of full thickness eyelid wedge for resection is deter-
mined by overlapping one vertical cut edge of the lower eye-
lid and resecting the redundant lower eyelid to obtain a tight
eyelid. The eyelid edges are approximated with tarsal and lid
margin sutures which avoid corneal contact. The wedge
resection can be utilized for mild, moderate, or severe hori-
zontal lower eyelid laxity as well as ectropion and entropion
of the lower eyelid. However, when there is a negative can-
thal tilt (Fig. 7e) and a soft tissue to bone distance greater
than 1 cm (Fig. 7c), a horizontal lid shortening by pentagonal
wedge resection is contraindicated. Lower eyelid malposi-
tion combined with a negative canthal tilt requires a proce-
dure that includes horizontal lid shortening and lateral
canthal elevation such as the tarsal strip canthalplasty.
Pentagonal wedge resection addresses only one aspect of
the lower eyelid malposition, namely, excess horizontal
length. It is a useful procedure for lower eyelid malpositions
caused by orbicularis oculi muscle paralysis, ectropion,
entropion, and senile lid margin eversion.
4 Tarsal Strip (TS) Lateral Canthoplasty
Lateral canthal procedures that combine horizontal lower
eyelid shortening at temporal extreme of the lower eyelid
with firm fixation to the lateral orbital region are tarsal fixa-
tion procedures. When there is ectropion without mid-
lamellar vertical restriction, the tarsal strip procedure
combined with midfacial suspension is recommended.
792
Fig. 8 The inferior retinacular lateral canthal procedures. (a) The
IRLCx and IRLC procedures are performed through the lateral aspect of
an upper eyelid blepharoplasty incision. A skin-muscle flap is elevated
along the lateral orbit, exposing the lateral lower eyelid fat. The inferior
aspect of the lateral retinaculum of the lateral canthus lies immediately
superior to this fat. The lateral fat can be removed to better expose the
inferior retinaculum. After removal of the fat, a “cave” is revealed, the
roof of which corresponds to the inferior retinacular component of the
lateral canthal retinaculum passing from the lower lid tarsoligamentous
structure to the bony orbital tubercle of Whitnall. The inset illustrates
this relationship as it would be visualized from within the orbit. (b) The
inferior retinacular lateral canthoplasty (IRLC) procedure is performed
G.W. Jelks and E.B. Jelks
by lysis of the inferior retinacular component and suture fixation to the
inner aspect of the bony orbital rim periosteum. Inset illustrates the infe-
rior retinacular lateral canthopexy (IRLCx) which does not lyse but pli-
cates and anchors the lower eyelid component of the inferior retinaculum
to the inner aspect of the bony lateral orbital rim. (c) The IRLC proce-
dure where both needles of a 4-0 Polydek suture have been passed into
the cut distal end of the inferior retinacular structure as a hitching stitch
(arrow). The suture is then passed through the inner aspect of the bony
lateral orbital rim periosteum at a level corresponding to the superior
edge of the pupil with the globe in straight ahead gaze (dotted line). The
suture can be adjusted and tightened so the lower eyelid margin covers
1–2 mm of the inferior cornea (Modified from Jelks et al. [22])
Lateral Canthal Surgery in Blepharoplasty
Fig. 9 (a) Preoperative blepharoplasty candidate with negative vector
and less than 1 cm distance from the lateral commissure to lateral orbital
bone. (b) Patient 1 year postoperative from upper and lower blepharo-
plasty with inferior retinacular lateral canthoplasties. Note the palpebral
apertures remain at the same horizontal dimensions (vertical lines)
Fig. 10 Horizontal pentagonal wedge resection of the lower eyelid
performed at the lateral lower eyelid
793
Fig. 11 The tarsal strip lateral canthal procedure divides the lateral pal-
pebral commissure (canthotomy) and selectively releases the lower eye-
lid (cantholysis) from the orbital tubercle. The amount of horizontal lid
shortening can be varied with the amount of temporal lower lid tarsal
baring of epithelial and conjunctival structures which creates a tarsal
strip. Careful positioning of the tarsal strip is performed by suture
placement and fixation into the inner aspect of the orbital bone perios-
teum at an elevated position corresponding to the upper level of the
pupil with the eyes in primary gaze (dotted line)
Whenever there is mid-lamellar cicatricial restriction, the
addition of a vertical lower eyelid spacer graft (cartilage,
palatal mucosa) with midfacial suspension is recommended.
The tarsal strip lateral canthal procedure divides the lat-
eral palpebral commissure (canthotomy) and selectively
releases the lower eyelid (cantholysis) from the orbital tuber-
cle (Fig. 11). The amount of horizontal lid shortening can be
varied with the amount of temporal lower lid full thickness
resection or tarsal baring of epithelial and conjunctival struc-
tures to create a tarsal strip. Some lateral tarsal shortening
procedures suture the lateral lower lid tarsal structure to the
same position on the lateral orbital bony rim and other proce-
dures suture the lower lid lateral tarsal structures to different
position on the lateral orbital rim.
The use of drill holes in the lateral orbital bone may be
necessary. The tarsal strip procedure, with its many varia-
tions (see Fig. 2), is useful for the correction of moderate-to-
severe lid margin eversion, paralytic ectropion, and
unrecognized horizontal lid laxity after blepharoplasty. It is
relatively contraindicated when lateral commissure to bony
orbit distance is greater than 1 cm, and the patient has a nega-
tive vector relationship with a prominent globe and bone to
soft tissue distance greater than 1 cm.
Under these anatomical circumstances, the lateral can-
thotomy and inferior retinacular cantholysis may result in
inability to fix the lower lid tarsal strip to the lateral orbital
rim. The distance may have to be made up with a dermal
794
Fig. 12 (a) Patient exhibiting post-blepharoplasty complications of
scleral show, temporal lower eyelid eversion without vertical mid-lamellar
eyelid restriction. (b) The tarsal strip (horizontal lid shortening) prepared
orbicular pennant (DOP) flap (see below), fascial graft, peri-
osteal flap, or suture suspension.
The tarsal strip lateral canthal procedures produce a
decrease in the horizontal dimension of the lower eyelid, giv-
ing the appearance of a “beady eye” (Fig. 12). Deformity of
the lateral lower eyelid at the lateral commissure with lack of
contact with the globe, webbing and trichiasis may occur fol-
lowing tarsal strip lateral canthal procedures.
5 Dermal Orbicular Pennant Lateral
Canthoplasty (DOPLC)
Dermal orbicular pennant was developed for management of
the primary and secondary blepharoplasty patient who has a
greater than 1 cm distance from the lateral commissure to the
bony orbital rim. The DOPLC also reduces or eliminates the
lower eyelid deformities caused by the tarsal strip lateral
canthoplasties. It also reduces the incidence of the “beady
eye” syndrome since it is performed without decreasing the
horizontal dimension of the lower eyelid. The DOPLC pro-
cedure uses an extension of the lower eyelid in the form of a
de-epithelialized pennant of skin and orbicularis oculi mus-
cle. A lateral canthotomy (separation of the upper and lower
eyelids at the lateral commissure) is not performed; there-
fore, lateral palpebral commissure deformities are reduced
and shortening of the horizontal dimension of the lower eye-
lid is avoided. The preferred technique is to develop a hori-
zontally oriented dermal-orbicular pennant measuring
0.5–1.0 cm in height and 1–2 cm in length from the lateral
palpebral commissure (Fig. 13). The pennant is completely
separated from the upper eyelid pretarsal, preseptal, and
orbital orbicularis oculi muscles. The pennant is separated
from the lower eyelid orbital and preseptal orbicularis oculi
muscle but left attached to the pretarsal segment of orbicu-
laris oculi muscle (Fig. 13). Release of the lower eyelid by
lysis of the inferior retinaculum similar to the lysis per-
G.W. Jelks and E.B. Jelks
for periosteal fixation on the right side. (c) Nine months after bilateral
tarsal strip horizontal lid shortening procedures (Note the decrease in hori-
zontal palpebral apertures (“beady eye” appearance) in Peck [39])
formed with the inferior retinacular lateral canthal procedure
allows the lower eyelid to be selectively elevated and tight-
ened (Fig. 13).
The dermal orbicular pennant lateral canthoplasty is
useful in secondary blepharoplasty operations for manage-
ment of lower lid malposition in patients with a bony orbital
rim to lateral commissure distance greater than 1 cm. The
amount of bony orbital rim to lateral palpebral aperture dis-
tance can be managed by varying the suture placement
from the dermal pennant into the bone periosteum for can-
thal elevation and tightening (Fig. 13). The suture can be
placed into the midportion or tip of the dermal orbicular
pennant flap to span the required distance to the bone peri-
osteum (Fig. 13). It is unusual to have a dermal orbicular
pennant flap that cannot span the soft tissue to bone dis-
tance. However, if this situation occurs, a suture suspension
or lateral orbital rim periosteal flap can be used to suspend
the lower eyelid.
One of the major advantages of the dermal orbicular pen-
nant lateral canthoplasty is the ability to correct significant
lower eyelid malpositions with maintenance of the horizon-
tal palpebral aperture dimensions (Fig. 14).
6 Horizontal Lid Shortening (HLS), Tarsal
Strip (TS), Dermal Orbicular Pennant
Lateral Canthoplasty (DOPLC), Vertical
Spacer Graft (VSG), Midfacial Soft (MFS)
Tissue To Bone Suspension
The dermal orbicular pennant flap with or without horizontal
lid shortening and vertical spacer grafts with midface sus-
pension has become the preferred method of surgical correc-
tion of complex lower eyelid malpositions. This use of
combinations of lateral canthal procedures and ancillary
techniques allows the surgeon to selectively release the lower
eyelid lateral canthal attachment to the bony orbit, correct
Lateral Canthal Surgery in Blepharoplasty
a b
d e
Fig. 13 (a) A horizontally oriented pennant 1 × .5 cm is incised through
the dermis. (b) The pennant is de-epithelialized to form a dermal orbic-
ular pennant connected to the lateral commissure. (c, d) The dermal
orbicular pennant is incised superiorly through the pretarsal, preseptal,
and orbital portions of the orbicularis ocluli muscle but only through the
orbital and preseptal portions of the orbicularis oculi muscle inferiorly.
The pretarsal orbicularis oculi muscle remains attached to the elevated
dermal orbicularis oculi pennant flap. Note that the lateral commissure
remains intact. (d) When the dermal orbicular pennant flap is elevated
mid-lamellar cicatricial retractions, perform horizontal lid
shortening and orbicularis oculi redraping with midface and
cheek suspension.
After elevation of the dermal orbicular pennant flap, the
cheek, lower eyelid, and midface can be elevated and released
from all cicatricial and retraction forces (Fig. 15). If lower
eyelid cicatricial retraction is corrected and results in more
than a 1 cm vertical space between the inferior border of the
tarsus and the incised capsulopalpebral fascia, a vertical
spacer graft is inserted (Fig. 16). Autogenous auricular carti-
lage is preferred and does not have to be covered with con-
junctiva. However, other material can be utilized (Table 3).
The cheek and midface can now be elevated from a subperi-
795
c
it distracts the inferior retinacular portion of the lateral retinaculum into
view. This can be incised (dotted line) thus releasing the lower eyelid
from the attachment to the lateral retinaculum. (e) The distracted der-
mal orbicular pennant remains attached to the lower lid via the pretarsal
muscle. The dermal orbicular pennant can then be sutured to the inner
aspect of the orbital rim periosteum at a level corresponding to the
upper level of the pupil in primary gaze. Note the slight distortion of the
lateral commissure with elevation and tightening of the dermal orbicu-
lar pennant
osteal or supraperiosteal plane through the lateral canthal and
or buccal sulcus. The use of drill holes in the zygoma and
maxilla and titanium screw into the malar bone with attached
double armed sutures to fixate the midfacial tissue maintains
cheek and midfacial suspension. The point of drill hole or
screw placement may vary from the lateral orbital rim to the
zygoma prominence. If horizontal lid shortening is required,
the dermal orbicular pennant is left intact and a lateral can-
thotomy is performed separating the upper and lower eyelids
at the lateral commissure just as in a tarsal strip lateral canthal
procedure. The temporal tarsus is bared of conjunctiva, cilia,
skin, and muscle for the required amount of horizontal lid
shortening. The cheek suspension is performed with bone
796 G.W. Jelks and E.B. Jelks

Fig. 15 (a) The dermal orbicular pennant (DOP) has been made con-
tiguous with an 8 mm tarsal strip formed by removal of lid margin, cilia,
conjunctiva, muscle, and skin fashioned from the lateral lower eyelid.
Note that a complete lateral canthotomy and lyis of the inferior reti-
nacular structures has been performed. The new lateral commissure
will be formed by moving the new lower lid margin to the upper lid,
thereby shortening the lower eyelid by 8 mm. (b) The tarsal strip has
been advanced to the new lateral commisure by passing the dermal
orbicular pennant and the tarsal strip behind the upper eyelid lateral
canthal structure. It is fixed to the inner aspect of the lateral orbital rim
with 4-0 polydek. The vertical mid-lamellar cicatrical retraction has
been released and an auricular cartilage graft inserted. Note the forma-
tion of a new lateral canthal commissure (star). The redundant dermal
orbicular pennant (DOP) is used to provide coverage of the lateral
orbital bone

fixation and the tarsal strip lateral canthal procedure com-

pleted with no tension. The remaining dermal orbicular pen-
nant is used to augment the midfacial suspension (Fig. 17).

6.1 Summary

The distance from the lateral palpebral commissure to the

Fig. 14 (a) Patient with bilateral 1 mm of scleral show, lower eyelid
horizontal laxity, negative vector relationship, negative canthal tilts, and bony orbital rim is the single most important measurement in
lateral commissure to lateral bone rim distance greater than 1 cm. (b) choosing between a canthopexy, canthoplasty, or dermal
The patient 9 months after blepharoplasty and bilateral dermal-orbicular orbicular pennant lateral canthoplasty (see Fig. 7c). If the
pennant lateral canthoplasties with midfacial and cheek suspensions.
bone to soft tissue distance is less than 1 cm, a horizontal
Note the maintenance of the horizontal palpebral apertures
Lateral Canthal Surgery in Blepharoplasty
wedge resection performed in the lateral lower eyelid, tarsal
strip, inferior retinacular lateral canthopexy (IRLCx), or
inferior retinacular lateral canthoplasty (IRLC) procedures
are preferred. If the distance is greater than 1 cm (prominent
Fig. 16 Auricular cartilage graft sutured as a vertical spacer graft into
the lower eyelid from the inferior border of the tarsus to the retracted
edges of the middle lamella and conjunctiva. The cartilage is not cov-
ered with conjunctiva
Fig. 17 (a) Patient with abnormal palpebral apertures with ectropion,
lid margin eversion, and scleral show: negative vectors, horizontal lid
laxity, negative canthal tilts, vertical mid-lamellar restriction, and mid-
facial descent. (b) Patient 1 year after dermal orbicular pennant and
797
globes, high myopia, thyroid orbitopathy, malar hypoplasia,
and negative vector relationship), a dermal orbicular pennant
lateral canthoplasty is recommended. When the diagnosis of
horizontal lid laxity is made with the positive distraction and
snap test of the lower eyelid (see Fig. 7d), a horizontal lid
shortening procedure is required. However, when there is a
negative canthal tilt (see Fig. 7e) and a soft tissue to bone
distance greater than 1 cm, a simple horizontal wedge resec-
tion is contraindicated and lateral canthal procedures that
include horizontal lid shortening and lateral canthal eleva-
tion must be used.
Whenever there is a vertical cicatrical retaction of the mid
lamella of the lower eyelid greater than 1 cm in vertical
dimension, a spacer graft of autogenous material is required.
The lower eyelid and lateral canthus cannot support the
cheek and midface. If midfacial descent is diagnosed, the
cheek and midface must be elevated with bony fixation to
support the lateral canthus and lower eyelid position. The use
of titanium screws, bone drill holes, and fascial suspension is
required in these circumstances.
To determine which type of lateral canthal procedure to
utilize is directly related to the identification of seven cardinal
physical diagnostic findings: (1) palpebral aperture, (2) vec-
tor relationship, (3) horizontal lid laxity, (4) soft tissue to
orbital bone distance, (5) canthal tilt, (6) mid lamellar verti-
cal lower eyelid retraction, and (7) midfacial descent.
tarsal strip horizontal lid shortening, release of mid-lamellar vertical
restriction and insertion of auricular cartilage vertical spacer grafts,
midfacial suspension with bone fixation
798
Simple horizontal lid shortenings and lateral canthal fixa-
tion procedures are useful adjuncts to blepharoplasty.
Identification of the seven cardinal physical findings pro-
vides a means of determining which type of lateral canthal
procedure and ancillary techniques will be required to man-
age the lower eyelid malposition. In general, the more severe
the preoperative physical findings, the more complex the
eyelid reconstructions [38].
References
1. Gioia VM, Linberg JV, McCormick SA (1987) The anatomy of the
lateral canthal tendon. Arch Ophthalmol 105:529–532
2. Edgerton MT, Wolfort FG (1969) The dermal-flap canthal lift for
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12. Jordan DR, Anderson RL (1989) The lateral tarsal strip revisited.
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14. Whitaker LA (1984) Selective alteration of palpebral fissure form
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16. Patterson RS, Munro IR, Farkas LG (1987) Transconjunctival lat-
eral canthopexy in Down’s syndrome patients: a nonstigmatizing
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17. Shore JW (1985) Changes in lower eyelid resting position, move-
ment, and tone with age. Am J Ophthalmol 99:415–423
18. Flowers RS (1993) Canthopexy as a routine blepharoplasty compo-
nent. Clin Plast Surg 20:351–365
19. McKinney P (1977) Use of tarsal plate resection in blepharoplasty
on atonic lower lids. Plast Reconstr Surg 59:649–652
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20. Hinderer UT (1993) Correction of weakness of the lower eyelid and
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27. Patipa M (2004) Transblepharoplasty lower eyelid and midface
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plasty. Oper Tech Plast Surg 5:90–98
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(2005) Lateral canthal anchoring: special situations. Plast Reconstr
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current techniques. In: Mathes SJ (ed) Plastic surgery. Saunders
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tic surgery. Al Gower Medical Publishing, New York, p 5
 Complications of Aesthetic
Blepharoplasty and Revisional
Surgeries

Richard D. Lisman and Christopher I. Zoumalan

1 Introduction • Dry eye

• Eyelid hematoma
Blepharoplasty has traditionally been one of the most com- • Infection
mon aesthetic procedures performed and remains so today. • Eyelid sloughing
Blepharoplasty is performed by a variety of surgeons with • Chemosis
different training levels of experience including plastic sur- Intermediate (weeks 1–6)
geons, ophthalmologists, otolaryngologists, cosmetic sur- • Upper eyelid malposition
geons, and dermatologists. Although relatively – Ptosis
straightforward, complications ranging from mild skin blem- – Lagophthalmos
ishes to vision-threatening emergencies can arise postopera- • Lower eyelid malposition
tively. Many of these complications can be prevented with • Corneal exposure
careful preoperative evaluation and proper surgical tech- • Strabismus
nique. When complications do arise, their significance can Late (>6th week)
be diminished by appropriate treatment and/or referral con- • Upper eyelid malposition
sultation when necessary. – Ptosis
This chapter presents postoperative complications from – Lagophthalmos
blepharoplasty based upon timeframe from surgery (i.e., early, • Lower eyelid malposition
intermediate, and late postoperative periods) and offers guid- • Over- and under-resection of skin
ance for treatment and/or possible measures for prevention. It • Over- and under-resection of orbital fat
is important to realize that some complications may arise in • Eyelid crease abnormalities
during various postoperative timeframes. Early recognition • Malar festoons
and appropriate treatment is essential, but the best therapeutic • Suture tracks
option often differs based upon the timing from surgery. • Hypertrophic scarring
This chapter provides an overview of the most common • Dermal pigmentation
and concerning complications allowing the reader to develop • Alopecia of lashes and chalazia
appropriate clinical perspective. • Dry eye syndrome
• Palpebral fissure asymmetries
Blepharoplasty complications • Eyelid granulomas
Early (1st week)
• Visual loss
– Orbital hemorrhage
– Globe perforation 2 Complications in the Early
– Central retinal artery occlusion Postoperative Period (1st Week)
• Corneal abrasion
2.1 Visual Loss
R.D. Lisman, MD, FACS (*) • C.I. Zoumalan, MD
Division of Ophthalmic Plastic and Reconstructive Surgery, The most feared complication of blepharoplasty surgery is
Department of Ophthalmology, New York University School of visual loss. The most common cause is orbital hemorrhage,
Medicine, New York, NY, USA
although other etiologies have been reported (i.e., globe
e-mail: drlisman@lismanmd.com

© Springer Berlin Heidelberg 2016 799

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_57
800 R.D. Lisman and C.I. Zoumalan

perforation, central retinal artery occlusion, retrobulbar optic a

neuritis, angle closure glaucoma).
A past ocular history is important to identify any prior
ocular disorders (i.e., dry eye syndrome) and rule out preex-
isting causes of visual dysfunction, as rare reports of mal-
practice cases where patients with a preexisting visual deficit
have attempted to claim visual loss as a consequence of
blepharoplasty do exist.

2.2 Orbital Hemorrhage

The incidence of orbital hemorrhage, which is also referred

to as a retrobulbar hemorrhage, has been reported in the plas- b
tic surgery literature at 0.04 % [1]. This was confirmed more
recently by a large study that surveyed oculoplastic special-
ists that performed more than 250,000 blepharoplasty cases
and found the incidence of orbital hemorrhage to be 0.05 %.
The associated incidence of permanent visual loss secondary
to a hemorrhage was much less at 0.0045 % [2].
We can speculate that with such data, there is a 1/2,000
risk of significant hemorrhage and a 1/10,000 risk of perma-
nent visual loss. The most likely clinical presentation of an
orbital hemorrhage is usually within the first 24 h after sur-
gery, although bleeding has been reported as late as 9 days
after surgery [3]. Patients will usually complain of pain,
pressure, diplopia, and visual loss. Examination reveals sig-
nificant proptosis, inability to open eyelids due to the
increased orbital pressure from the hemorrhage, increased Fig. 1 (a, b) Orbital hemorrhage producing ecchymosis after a frontal
intraocular (tonometry) pressure, decrease in visual acuity, nerve block during transcutaneous blepharoplasty (a) and orbital hem-
extraocular motility disturbance, and an afferent pupillary orrhage in a hypertensive patient demonstrating sudden proptosis and
chemosis (b)
defect (Fig. 1).
Various theories attempt to describe the etiology of an
orbital hemorrhage, but the most common reason is vascular connecting the anterior orbital fat to deep orbital fat
trauma. The final common pathway involves continued underscores the necessity to avoid excessive traction dur-
orbital bleeding leading to increased intraorbital and intra- ing fat excision [4]. During eyelid surgery, it is advanta-
ocular pressure with resultant ischemic damage to the retina geous to delay wound closure by proceeding to another
and/or optic nerve. surgical site, returning later to re-assess hemostasis prior
Key pearls to avoiding orbital hemorrhage include the to suturing.
following:
Postoperative prevention of hemorrhage involves all of
• Detailed preoperative evaluation with particular attention the following:
to medical problems such as diabetes, hypertension,
smoking tobacco, coagulopathies and both prescription • Elevating the head of the bed to decrease intravascular
and over-the-counter anticoagulant medication use. pressure.
Patients should also be screened for any herbal medica- • Avoiding a valsalva response, which can result in a sud-
tions that may decrease coagulation (i.e., ginseng, ginkgo den rise in intraorbital pressure and secondary bleeding.
biloba, vitamin E, and garlic). Stopping all anticoagulants Consultation with the anesthesia team should include rou-
and herbal medications for up to 2 weeks in advance to tine postoperative antiemetics, and when necessary, cough
allow normalization of bleeding parameters and platelet suppressants.
function is important. • Avoid pressure dressings or eye patches as they delay
• Intraoperative control of hemostasis is critical. Koorneef’s diagnosis. But we do recommend placing routine ice
description of the delicate connective tissue scaffold compresses on the operated eye.
Complications of Aesthetic Blepharoplasty and Revisional Surgeries 801

Once the patient is in the postoperative recovery area and a

awake, the patient should have their visual acuity evaluated
by confirming if they can at least count fingers. If the patient
cannot count fingers but only detect hand motions or light
perception, this would be a cause for concern and further
evaluation. Recovery staff should be instructed to test the
vision in each eye individually.

2.2.1 Management of Orbital Hemorrhage

Once the diagnosis of orbital hemorrhage is made, the treat-
ment requires immediate attention. Ophthalmology consul-
tation is recommended to help in the evaluation and
management. The first step should be to identify those hem-
orrhages that require medical or surgical care, based on the
b
ophthalmic examination. If the intraocular pressure is ele-
vated, as measured by tonometry or emergently by tactile
evaluation, topical and systemic glaucoma medications can
be used. Systemic corticosteroids are used for significant
edema. When the bleeding threatens the visual system, or is
worsening, surgical therapy is urgently required. The first
step is to open the incision widely through the orbital septum
and explore the surgical site and orbit for signs of bleeding.
Clots are evacuated and cautery is applied when bleeding
sites are identified. If the condition remains unresponsive,
a lateral canthotomy and cantholysis is performed (Fig. 2).
In severe cases, both the inferior and superior crus of the
lateral canthal tendon can be released. Fig. 2 Canthotomy consists of surgically dividing the superior and
However, when these measures fail, an emergent CT scan inferior crura of the lateral canthal tendon (a). Cantholysis refers to
without contrast is warranted. If there is a posteriorly orga- lysis of the inferior (and sometimes superior) crus of the lateral canthal
nized hemorrhage, bone decompression may be warranted to tendon (b)
relieve orbital apex compression (Fig. 3).
The treatment should be aggressive for the first 24–48 h
postoperatively, as vision has been reported to return in
patients with “no light perception” that was present for 24 h.

2.3 Globe Perforation

Inadvertent globe penetration can result from any periocular

procedure. Caution is required during local anesthetic injec-
tion, particularly in the thin upper eyelid of older patients.
Prevention of this complication begins with the use of pro-
tective corneal shields during injection and surgery. Corneal
shields should be lubricated with ophthalmic ointment prior
to placement within the lids to avoid a corneal abrasion. The
range of potential ocular damage from penetration includes a
large conjunctival or scleral laceration, corneal perforation,
traumatic cataract, intraocular hemorrhage, retinal tears, and
detachment.
Perforation of the globe is an ophthalmic emergency and
Fig. 3 CT scan after transcutaneous blepharoplasty showing aggre-
necessitates emergent consultation with an ophthalmologist. gated clot and hemorrhage in the orbital apex. Posterior findings create
A Fox shield should be placed over the eye in the interim and the possibility for treatment with decompression rather than lateral
the patient should be instructed not to rub or press on the eye. canthotomy
802
How to place a corneal protective lens:
• Instill a tetracaine or proparacaine ophthalmic eye drop
into the eye
• Lubricate the protective shield with ophthalmic ointment
• Insert the shell under the superior fornix from below
• Evert the lower eyelid to allow the lower edge of the shell
to move into the inferior fornix
How to remove a corneal protective lens:
• Instill a tetracaine or proparacaine ophthalmic eye drop
into the eye
• Gently place an ocular muscle hook posterior to the lower
edge of the shell
• Guide the shell inferiorly over the lower lid
2.4 Central Retinal Artery Occlusion
The potential for central retinal artery embolization follow-
ing facial and periocular injection has been reported and is
secondary to retrograde arterial displacement of the foreign
substance from a peripheral arteriole into the ophthalmic
arterial system [5, 6].
2.5 Corneal Abrasion
The diagnosis of a corneal abrasion is made by patient symp-
toms (sharp, stabbing pain, foreign body sensation, light sen-
sitivity) and is usually apparent immediately after surgery.
The diagnosis is confirmed by evaluating the cornea under a
cobalt blue light after instillation of fluorescein drops. Even
though corneal abrasion is the leading cause of ocular pain
and irritation following blepharoplasty, patients that com-
plain of severe eye pain should be carefully examined under
a slit-lamp to rule out globe perforation.
Abrasions are often caused by drying of the corneal sur-
face during surgery or inadvertent damage to the surface cor-
neal epithelial layer. Sometimes, taping of the eyes during
anesthetic induction causes an abrasion if the eyes are acci-
dentally taped in an open position.
Careful insertion and removal of well-lubricated corneal
shields prevents this complication; as does the use of oph-
thalmic ointment into each eye at the completion of the pro-
cedure. Abrasions can be treated with ophthalmic antibiotic
ointment four times daily, and should be resolved within
24–48 h. Patching should be avoided, as it may mask a more
serious complication, such as an orbital hemorrhage.
Persistent signs and symptoms should prompt ophthalmo-
logic evaluation.
R.D. Lisman and C.I. Zoumalan
2.6 Dry Eye
Corneal irritation from dry eyes is somewhat common after
blepharoplasty and symptoms are similar to, but less severe,
than an abrasion. Patients may complain of foreign body sen-
sation, dryness, irritation, blurry vision, photosensitivity, and
redness. These symptoms often arise from dried accumula-
tion of clot or ointment on the eye and will respond to ocular
lubrication with preservative-free teardrops and cool com-
presses. Alternatively, poor eyelid closure can cause expo-
sure keratopathy, particularly along the inferior cornea. This
diagnosis is made with a slit-lamp examination after the
instillation of fluorescein drops. The examiner will see punc-
tate corneal staining under blue light illumination in the
affected region of the cornea. Lubricating drops and oint-
ment are often effective treatment measures.
2.7 Eyelid Hematoma
Eyelid hematomas usually develop from bleeding of the
orbicularis oculi muscle. Patients with a hematoma should
be evaluated for symptoms consistent with orbital hemor-
rhage. Unlike orbital hemorrhages, eyelid hematomas do not
result in a posterior bleed, and as a result, patients do not
present with proptosis or increased intraorbital pressure.
Once an orbital hemorrhage is ruled out, mild superficial
hematomas can usually be treated conservatively with ice
compresses. Larger, stable hematomas should be followed
for 7–10 days until adequate resolution of the hematoma has
occurred. Rarely do they need to be drained by needle aspira-
tion or reopening of the wound. In severe cases, they may
result in tissue fibrosis and lid scarring. Expanding hemato-
mas require immediate surgical exploration, evacuation and
control of the bleeding source.
2.8 Infection
The development of cellulitis or abscess formation is exceed-
ingly rare in the well-vascularized eyelid. Preseptal cellulitis
presents with erythema and induration around the eyelids
and is usually confined anterior to the orbital septum.
Treatment usually responds to oral or intravenous antibiotics.
Preseptal cellulitis tends to be a less severe disease than
orbital cellulitis (postseptal cellulitis), which can present in a
similar manner.
Orbital cellulitis has a higher morbidity, requires aggres-
sive treatment, and may require surgical intervention.
Patients present with proptosis, excessive pain, eyelid swell-
ing, erythema, conjunctivitis, decreased visual acuity, dimin-
ished extraocular motility and pupillary abnormalities.
Contrast-enhanced computed tomography is effective in
Complications of Aesthetic Blepharoplasty and Revisional Surgeries 803

Fig. 4 Three days postoperatively, a blepharoplasty patient developed

pseudomonas cellulitis with associated abscess formation

diagnosing an orbital abscess. Patients are managed by cul-

turing any purulent discharge that is present and then begin-
ning broad-spectrum intravenous antibiotics for 7–10 days.
Abscesses usually require surgical drainage.
Figure 4 shows a patient who developed a pseudomonas
preseptal cellulitis in three of four lids after blepharoplasty.
She was treated with a combination of surgical drainage and
intravenous antibiotics, but ultimately developed late cicatri-
zation and skin dimpling.

2.9 Eyelid Sloughing

Eyelid necrosis is a rare complication and can follow inad-

vertent injection with formaldehyde or other substances (i.e., b
atropine, alcohol, boric acid) instead of local anesthetic.
Complete eyelid sloughing can develop, necessitating mul-
tiple eyelid reconstructive procedures which can ultimately
place the patient at risk for cicatricial changes, persistent lag-
ophthalmos and chronic ocular irritation from dry eye symp-
toms (Fig. 5).

2.10 Chemosis

Chemosis is also referred to as conjunctival edema. It can

develop in the early or intermediate postoperative period due
to various etiologies such as incomplete eyelid closure, ocular c
allergy, sinusitis, or postsurgical edema. Chemosis can be
worsened by systemic conditions such as renal failure (Fig. 6)
or thyroid eye disease. Corneal drying may occur, as the

Fig. 5 Severe eyelid sloughing is seen in a patient after injection with

formalin (a, b). The surgeon was inadvertently handed formalin instead
of local anesthesia and the patient immediately complained of pain.
Four stages of eyelid reconstruction were needed to provide sufficient
corneal coverage (c)
804
Fig. 6 A patient with chronic renal failure who developed postoperative
chemosis following lower eyelid blepharoplasty (a). Lubrication and
time allowed significant resolution of the chemosis over 6 months. Note
that mild persistent chemotic conjunctiva is present and can be a man-
agement problem in patients with underlying thyroid or renal disease (b)
edematous conjunctiva balloons around the cornea preventing
adequate tear film dispersion. Additionally, the exposed con-
junctival surface may keratinize, leading to worsening foreign
body sensation and ocular irritation. Treatment usually
involves preservative-free artificial tears and ointment. A mild
topical steroid eye drop can be prescribed, but should only be
given in conjunction with ophthalmic evaluation to assure
normalcy of the intraocular pressure and to rule out secondary
infectious keratitis. A temporary suture tarsorrhaphy may be
needed in chronic cases.
3 Complications in the Intermediate
Postoperative Period (1st–6th Week)
3.1 Ptosis
Postoperative ptosis can be seen frequently following upper
eyelid blepharoplasty (Fig. 7). Often, this subtle levator
attenuation seen in aponeurotic ptosis is present preopera-
tively, but goes undiagnosed [7].
R.D. Lisman and C.I. Zoumalan
Fig. 7 Preoperative photo of a patient with concomitant dermatochala-
sis and aponeurotic ptosis (a) who underwent upper eyelid blepharo-
plasty without addressing the underlying ptotic eyelids (b). Note the
residual blepharoptosis in the postoperative photo (b)
Pearls to evaluate for preoperative ptosis include the
following:
• Assure that the frontalis muscle is blocked when examin-
ing the upper eyelid position. Often patients with ptosis
and/or excessive dermatochalasis compensate with invol-
untary frontalis recruitment (Fig. 8).
• Carefully examine the margin reflex distance (MRD), pal-
pebral fissure height (PF), levator function (lid excur-
sion), and upper eyelid crease height. Patients with excess
upper eyelid tissue overhanging may mask a small MRD
and PF distance. Aponeurotic ptosis is often accompanied
by an increase in lid crease height, or a deep superior
sulcus.
• When measuring MRD and PF, simultaneously block the
frontalis muscle and mechanically lift the excess tissue.
• Plan a concomitant ptosis surgery along with blepharo-
plasty, if necessary.
• Mechanical ptosis can result from postoperative edema or
ecchymosis. This should resolve with conservative treat-
ment, including cool compresses. If the ptosis remains
persistent, it is possible that the edematous state led to
Complications of Aesthetic Blepharoplasty and Revisional Surgeries
a symptoms (foreign body sensation, tearing, irritation, photo-
b plication after lower eyelid blepharoplasty, which may range
Fig. 8 Significant frontalis recruitment noted in a patient with ptosis.
The brow position is elevated to compensate for the ptotic upper lids
(a). Note the change in brow position to a more normal position after
undergoing upper lid ptosis surgery (b)
levator attenuation. When persistent, the surgeon should
consider ophthalmic evaluation.
3.2 Lagophthalmos
As mentioned previously, lagophthalmos occurs frequently
in the postoperative period.
Reasons for lagophthalmos include the following:
• Excessive skin removal
• Surgical trauma to the orbicularis muscle
• Tethering of the eyelids by sutures or Steri-Strips (3 M,
St. Paul, MN, USA)
• Postoperative pain, leading to guarding and incomplete
lid closure
Inadequate eyelid closure can lead to patient discomfort
secondary to exposure keratopathy. The condition will be
worsened in those with preexisting dry eye disease or the
absence of an adequate Bell’s phenomenon. Preoperative
evaluation should include an assessment of ocular sicca
805
phobia, and dryness), signs (abnormal tear film, punctate
corneal staining, and decrease in basal tear secretion) and
adequacy of the Bell’s phenomenon. Lagophthalmos is usu-
ally temporary and conservative management in the interme-
diate postoperative period includes frequent lubrication, lid
massage, and lid taping.
3.3 Lower Eyelid Malposition
Lower eyelid malposition is the most common reported com-
from mild inferior scleral show in up to 20 % of patients to
severe cicatricial ectropion in 1 % (Fig. 9) [8, 9].
Patients present with epiphora and/or ocular irritation.
The punctum may be everted in association with an ectro-
pion, resulting in an elevated tear film and subsequent
epiphora.
Lid malposition is the result of an imbalance in lower eye-
lid forces. Abnormal downward forces can result from exces-
sive skin resection, scarring, imbrication of the orbital
septum, edema, and hematoma. Orbicularis oculi paralysis
additionally destabilizes the lower eyelid position.
Additionally, horizontal eyelid laxity should be evaluated
preoperatively. Evaluation of lower eyelid laxity can be done
using the snap-back and distraction tests. Eyelid snap-back is
evaluated by inferiorly displacing the lower eyelid centrally.
The lid should normally spring back into its position against
the globe. An abnormal result can be quantified by counting
the number of blinks required for the lower lid to regain its
normal position. The distraction test is performed by manu-
ally distracting the central aspect of the lower lid perpendicu-
larly away from the globe. Distraction of greater than 6–7 mm
indicates lower eyelid laxity. If lower eyelid laxity is found,
an appropriate tightening (i.e., lateral canthal resuspension,
horizontal shortening, medial canthopexy, lateral retinaculum
repair) should be performed at the time of blepharoplasty.
Preoperative identification of patients at risk for lower
eyelid retraction is of utmost importance in prevention of this
complication. Predisposing factors include the following:
• Globe proptosis
• High myopia
• Hypoplasia of the malar eminence
• Thyroid eye disease
• Lateral and medial canthal laxity
3.3.1 Management of Lower Lid Retraction
Mild eyelid retraction can often be managed with topical ste-
roid ointment and massage. The patient is instructed to mas-
sage the lower eyelid superiorly in the medial or lateral
806
a overcome the forces of significant retraction. Most aesthetic
b
c Thyroid eye disease often presents with upper lid retrac-
Fig. 9 Postoperative lower eyelid malposition after blepharoplasty can
result in a range of deformities from mild to moderate inferior scleral
show (a, b) to cicatricial ectropion (c) secondary to an infected malar
implant
one-third of the eyelid with a clean index finger. The lid
should be molded against the globe (never distracted away
from the globe) and stretched superiorly for 30–60 s.
A total of 5 min of eyelid stretching 2–3 times daily is
necessary. Additionally, if tolerated, the lower eyelid can be
stretched mechanically with Steri-Strips placed in a supero-
lateral direction from the lateral aspect of the lower eyelid.
Steri-Strips are only helpful in mild cases, since they cannot
R.D. Lisman and C.I. Zoumalan
patients prefer to use massage only.
Although cases of skin over-resection have become less
common with the popularity of transconjunctival blepharo-
plasty, a role still exists for the transcutaneous blepharo-
plasty. If skin over-resection is diagnosed early, skin sutures
can be removed at 2–3 days postoperatively, and the wound
is allowed to gap in order to granulate in the portion of the
eyelid. While not ideal, this option is better than the severe
bowing or ectropion that is likely to result, which will often
necessitate skin grafting. Similar wound gapping can be per-
formed with acceptable results in the upper eyelid. Massage
is needed during granulation to stretch and counter the forces
of contraction.
3.4 Corneal Exposure
As in the early postoperative period, keratopathy may persist
or become evident during the intermediate recovery period.
Similar to patients with early corneal irritation, sutures or
Steri-Strips may be tethering the eyelids since the orbicularis
muscle may not have regained its protractor abilities.
Additionally, over-resection of skin may become more
apparent as initial postoperative edema resolves. First-line
treatment generally involves frequent ocular lubrication and
taping, if necessary.
tion. Patients with upper lid retraction in the setting of der-
matochalasia should be screened for thyroid disease, since
undergoing blepharoplasty will unmask their lid retraction
and worsen their lagophthalmos (Fig. 10). In such instances,
the upper lid wound can be opened and allowed to granulate.
However, such patients may ultimately require surgery for
upper lid retraction (Fig. 10). Further treatment options are
usually reserved for later in the postoperative course.
3.5 Strabismus and Extraocular Muscle
Disorder
Diplopia is a rare, but a potentially disabling complication of
upper or lower eyelid blepharoplasty. It is common for
patients to complain of intermittent double vision following
blepharoplasty, often secondary to an abnormal tear film,
ophthalmic ointment, muscle contusion or temporary pare-
sis, hematoma or edema.
The following are the signs that make diplopia less worri-
some following surgery:
• Preoperative history of strabismus and diplopia
• Monocular diplopia (diplopia only when one eye is tested
and the other is occluded)
Complications of Aesthetic Blepharoplasty and Revisional Surgeries
a a
c
Fig. 10 A patient with undiagnosed thyroid eye disease with upper
eyelid retraction proceeds with upper lid blepharoplasty. Preoperative
photograph (a) demonstrates mild asymmetry of the palpebral fissures
with significant left upper eyelid retraction. One week postoperatively
(b) the retraction is obvious. The appearance is reasonably symmetric
after undergoing bilateral levator recession surgery (c)
• Diplopia that clears with blinking (suggestive of
precorneal tear film abnormality)
• Intermittent nature
Such patients should be treated with reassurance and
preservative-free artificial teardrops. Persistent binocular
diplopia requires additional consideration, especially if
807
Fig. 11 Example of a patient with right inferior oblique paresis follow-
ing transconjunctival blepharoplasty (a) with a close up view of the
patient in downgaze (b)
vertical. Transconjunctival and transcutaneous lower eyelid
blepharoplasty can each result in iatrogenic strabismus [10].
In both surgical approaches, the inferior oblique muscle is
most commonly injured (Fig. 11). Damage may be direct, or
secondary to aggressive cautery in the region between the
nasal and central fat pockets. Though not done routinely,
some surgeons attempt to identify the inferior oblique mus-
cle during fat resection under direct visualization.
Additionally, secondary blepharoplasty increases risk of
injury to the inferior oblique muscle as anatomic identifiers
may be ambiguous and fibrosis is often encountered.
Pearls to avoid damage to the inferior oblique muscle
include the following:
• The most direct route to the extraocular musculature is
through a deep forniceal incision. As a result, avoiding this
deep forniceal incision is crucial. The ideal location of an
incision is approximately 5–6 mm inferior to the inferior
tarsal border on the palpebral conjunctiva (Fig. 12).
• When in doubt intraoperatively, the inferior oblique mus-
cle can be identified lying between the nasal and central
fat pockets in the lower eyelid.
• Any clamping or traction on fat should not move the
globe. If this occurs, the surgeon should suspect that an
extraocular muscle is intertwined with the area of
resection.
808
incision site 6mm
inferior to tarsus
orbital fat
inferior oblique muscle
Fig. 12 The ideal lower eyelid transconjunctival blepharoplasty incision
should be made on the palpebral conjunctiva about 6-mm inferior to the
inferior tarsal border. Although a deep forniceal incision allows a more
direct route to the orbital fat compartments, it also places greater risk of
injury to the inferior oblique muscle (black straight line) and should be
avoided
The superior oblique muscle can be injured during upper
eyelid blepharoplasty, with mechanisms of injury similar to
inferior oblique damage. Injuries to the inferior and lateral
recti are exceedingly rare, but have been reported. The infe-
rior oblique muscle rides over the inferior rectus muscle,
making damage to the inferior rectus less likely.
Initial treatment of diplopia is conservative, as it often
resolves in the first few months as edema diminishes, even in
the setting of iatrogenic trauma. Patients with comitant mis-
alignment may be temporized with prismatic spectacles.
Expectant management is recommended until continued
improvement ceases, at which point consideration for surgi-
cal repair (strabismus surgery) may be advisable.
4 Complications in the Late
Postoperative Period (7th Week
and Beyond)
4.1 Ptosis
As discussed earlier, ptosis noted after blepharoplasty may
have been present preoperatively, stressing the importance of
careful initial examination. If this is not the case, the ptosis
may be the result of direct trauma to the levator aponeurosis
or secondary attenuation from postoperative edema or hema-
toma. Direct injury only occurs if the orbital septum was
opened intraoperatively. This complication can be avoided if
noted intraoperatively; as the damaged or disinserted levator
muscle can be sutured back into its original insertion onto
R.D. Lisman and C.I. Zoumalan
the superior aspect of the tarsus. If postoperative ptosis is
present, the patient should be followed for at least 3 months
prior to considering additional surgery. Many cases resolve
with time. Those that do not can be corrected with appropri-
ate blepharoptosis surgery, usually in the form of levator
reinsertion, a Fasanella-Servat procedure or muellerectomy.
We generally prefer performing a Fasanella-Servat proce-
dure for mild to moderate cases of ptosis. It allows us to cor-
rect for any overcorrection during the postoperative period
and to adjust for any asymmetry that may be present.
4.2 Surgical Technique: Fasanella-Servat
Procedure
After administration of local or general anesthesia and place-
ment of protective corneal shields, a typical blepharoplasty
incision is made along the upper eyelid crease with a #15
blade. If there is some residual dermatochalasia present, one
may consider performing a mild conservative resection of
skin during this procedure. However, if the patient has
already undergone a blepharoplasty, it may be wise to refrain
from any further skin resection. The upper eyelid is everted
and the posterior lamellae (conjunctiva and tarsus) are exam-
ined (Fig. 13). Next, two symmetrically shaped, curved
hemostat clamps are placed tip to tip for a tarsoconjunctival
resection of 2, 4, or 6 mm corresponding to the amount of lift
required (1, 2, or 3 mm, respectively) (Fig. 14). Care is taken
such that the central portion of the eyelid corresponded to the
largest amount of tarsal resection. A 5-0 nylon suture is
passed through the central aspect of the eyelid wound and
angled laterally to exit just beneath the clamps along the pos-
terior aspect of the eyelid (Fig. 15). The suture is passed in a
running, buried fashion beneath the hemostats from lateral to
medial. Each exit from one pass is used as the entry point for
the following pass, thereby burying all loops of the suture
(Fig. 16). The hemostats are used as guides for the tarsocon-
junctival resection by sliding a #15 blade above the clamps to
remove the desired amount of tissue and to protect the run-
ning suture (Fig. 17). The 5-0 nylon is passed from the pos-
terior and medial aspect of the tarsus and angled to exit just
adjacent to the opposite arm of the suture in the eyelid
wound. The suture is tied with multiple knots and left long
for externalization and easy retrieval. The eyelid wound is
closed with a running 5-0 nylon subcuticular suture, fol-
lowed by interrupted 6-0 nylon sutures laterally; the eyelids
are dressed with mastisol and Steri-Strips (3 M Healthcare,
St. Paul, MN, USA).
Patients are given TobraDex eyedrops (Alcon, Fort Worth,
TX, USA) and lubricating ointment postoperatively. If suture
exposure occurs and rubs on the cornea, a bandage contact
lens may be placed until the time of suture removal. Most
patients have sutures removed on postoperative days 5–7.
Complications of Aesthetic Blepharoplasty and Revisional Surgeries
Fig. 13 The upper lid is everted to evaluate the
tarsus
b
Fig. 14 Two clamps with similar arch/curvature are chosen (a) and
then they are placed tip to tip for a tarsoconjunctival resection (b)
4.2.1 Postoperative Adjustments
This adjustment can be a simple and effective component of
postoperative suture removal, allowing the Fasanella-Servat
procedure to become an adjustable ptosis repair. Six days
postoperatively, much of the edema has resolved but tissues
have not yet densely fibrosed. At this time, small manipula-
tions of soft tissue can be easily achieved. Minor asymme-
tries, eyelid peaking, and the potential height differential due
809
Fig. 15 A 5-0 nylon suture is passed through the central aspect of the
eyelid wound and angled laterally to exit just beneath the clamps
to Hering’s law can all be treated. In addition, this adjust-
ment involves minimal to no pain for the patient and does not
require anesthesia or sedation. Although some adjustments
treat frank overcorrections, most involve minimal sectoral
manipulations of the upper eyelid to smoothen contour and
improve symmetry. Furthermore, patients with mild under-
corrections of one eyelid can be improved with adjustment
(lowering) of the contralateral eyelid, thereby producing
increased innervation to raise the undercorrected eyelid by
Hering’s law.
4.3 Lagophthalmos
Lagophthalmos in the late postoperative period is the result
of excessive skin excision or incorporation of the orbital sep-
tum in skin closure resulting in eyelid retraction. Initial ther-
apy was described previously. If conservative therapy fails,
surgical correction should be considered at approximately 3
months postoperatively. Surgical options include elevation
810
Fig. 16 Each exit from one pass is used as the entry point for the fol-
lowing pass, thereby burying all loops of the suture
Fig. 17 The hemostats are used as guides for the tarsoconjunctival
resection by sliding a #15 blade above the clamps to remove the desired
amount of tissue
of the lower eyelid, skin grafting, or release of orbital-septal
adhesions.
R.D. Lisman and C.I. Zoumalan
Because of the aesthetic considerations in skin grafting,
lower eyelid elevation is often attempted first. If necessary,
skin grafts are best harvested from the opposing upper eye-
lid. Secondary choices include the postauricular and supra-
clavicular space.
As mentioned previously, thyroid eye disease can present
with upper lid retraction, which can result in lagophthalmos.
Patients with undiagnosed thyroid eye disease who undergo
blepharoplasty often unmask their lid retraction and have
worsening of lagophthalmos and keratopathy. Various surgi-
cal techniques can be performed to correct the upper lid
retraction, including recession of the levator aponeurosis and
muellerectomy. Recently, oculoplastic surgeons have found
success with a full thickness blepharotomy for upper eyelid
retraction in thyroid eye disease. This procedure, originally
described by Koorneef, has been reported to be successful in
post-blepharoplasty retraction [11] and may have an
increased role in years to come.
4.4 Lower Eyelid Malposition
Late lower eyelid malposition is complex and requires care-
ful consideration based on anatomic concepts. The lower
eyelid is broken into three lamellae. The anterior lamella is
comprised of skin and orbicularis muscle. The middle
lamella contains tarsus and orbital septum. The posterior
lamella is made up of the lower lid retractors and conjunc-
tiva. Identification of the affected lamella, usually the result
of deficient tissue, is the key to formulating a successful
reconstructive plan. Additionally, horizontal laxity must be
considered as a potential component of malposition.
An anterior lamellar deficiency is encountered after trans-
cutaneous blepharoplasty and can best be diagnosed by not-
ing lower eyelid movement with opening of the mouth. Frank
cicatricial ectropion can develop (Fig. 18). Most disease
states respond partially or completely to eyelid stretching.
Placing the eyelid on stretch as early as possible is advisable
(Fig. 19). Surgical repair often involves placement of addi-
tional skin to replace the deficient lamella. A combined lat-
eral tarsal suspension is appropriate if concomitant horizontal
laxity is present. Tarsal suspension may be done alone as an
indirect secondary procedure in those patients who are
unhappy with the thought of skin grafting (Fig. 20). These
patients often require overcorrection since gravity and mid-
facial movements will loosen the original position attained.
Middle lamellar deficiency is diagnosed by attempting to
stretch the central aspect of the lower eyelid superiorly.
A normal response is the ability to easily elevate the lower
eyelid over the inferior corneal limbus. If the eyelid will not
elevate, adhesions are present between the capsulopalpebral
fascia and the orbital septum or the anterior tissue and the
orbital septum. Successful repair in these instances requires
Complications of Aesthetic Blepharoplasty and Revisional Surgeries 811

Fig. 18 Cicatricial lower eyelid retraction from excessive skin excision

and anterior lamellar deficiency is best diagnosed by having the patient
open their mouth and observing inferior excursion of the lower lids

lysis of these adhesions if conservative stretching has failed.

Fig. 19 Postoperative view of a patient with cicatricial ectropion fol-
A lateral fixation procedure or occasionally posterior lamel- lowing translid removal of an infected malar implant (a). Aggressive
lar lengthening may be necessary. stretching and massage allowed some improvement and softening,
Posterior lamellar deficiency usually presents as entropion making it possible to attain a good lid position with a lateral tarsal sus-
with shortening of the inferior fornix. While rare, the repair pension (b). Starting the patient stretching early and often, even in
seemingly useless situations, is important
may involve addition of posterior lamella, such as hard palate
grafting or use of acellular dermis such as Alloderm (LifeCell).
5–7 mm (Fig. 21). With upward traction on the lateral aspect
4.4.1 Surgical Technique: Tarsal Suspension of the lower eyelid, the inferior crus of the canthal tendon is
Technique for Repairing Lower Lid severed with Stevens scissors (Fig. 22). The scissors are
Malposition directed posteromedially and the orbital septum is released
The general steps for the lateral tarsal suspension technique with sharp dissection (Fig. 23).
including the following: Next the tarsal strip is prepared by splitting the lateral
eyelid along the gray line, taking care to avoid cutting into
• Local anesthesia the tarsus (Fig. 24). Next, a horizontal incision is made along
• Lateral canthotomy the inferior border of the tarsal plate to detach the lower lid
• Inferior cantholysis retractors and conjunctiva. The posterior conjunctiva may or
• Release the orbital septum may not be shaved off with a #15 blade (Fig. 25).
• Development of the strip In order to determine the strip length, the terminal edge of
• Opening of a periosteal slot the tarsal strip is grasped and pulled laterally and slightly
• Reattachment of the strip superiorly towards Whitnall’s tubercle until appropriate
• Resupporting the strip height, tension, and contour are achieved. Attention should
• Lateral canthal angle reformation be made to confirm the correct position of the punctum. Care
• Closure of the lateral skin incision is taken not to place too much tension with the strip so as the
lower lid inadvertently “rides” below the globe.
A number 15 blade is used to create a lateral canthal inci- A periosteal slot is indirectly opened at the inner aspect of
sion in an aesthetically pleasing skin fold of approximately the lateral orbital rim with a number 15 blade (Fig. 26). The
812 R.D. Lisman and C.I. Zoumalan

Fig. 20 Preoperative photo of lower lid retraction after undergoing

bilateral lower lid transcutaneous blepharoplasty (a). Postoperative
photographs demonstrating efficacy of a lateral tarsal suspension (b)
Fig. 21 Lateral canthal incision
soft tissues are pushed with a swab to indirectly feel the lat-
eral orbital rim. This creates a “tongue and groove” siding
such that the strip fits into the groove within the periosteal
opening.
The tarsal strip is then secured to the periosteum on the
inner aspect of the lateral orbital rim with a 4-0 Polydek
suture on double armed, P-2 needles. The first needle is
sutured through the superior portion of the tarsal strip, the
second one is sutured through the inferior tarsus. The
superior suture is first grasped and used to engage the perios-
teum on the inner aspect of the rim within the groove. Lid
height and contour is assessed by pulling the upper suture. If
necessary, the suture can be backed out and repassed to
improve contour or height. A slight overcorrection in taut-
ness and height is desired to allow for mild relaxation of the
tissue in the early postoperative period. The inferior tarsal Fig. 22 Inferior cantholysis
suture is then passed in a similar fashion approximately
2–3 mm inferior to the superior suture arm (Fig. 27). (“belt and suspenders” technique) and to bury the underlying
The Polydek suture must be cut close to the knot. Any Polydek suture (Fig. 28).
exposed Polydek is prone to deeper epithelial inclusion Once the lateral strip is suspended properly, attention
cysts. A second suture (absorbable suture such as a 4-0 should be made at the lateral portion of the lower lid to iden-
polydioxanone) is then used to further secure the tarsal strip tify any prolapsed orbital fat or pleating of the orbicularis
Complications of Aesthetic Blepharoplasty and Revisional Surgeries
Fig. 23 Orbital septal release. Note the ability to fully distract the
lower lid from the globe secondary to complete release of the inferior
crus of the canthal tendon and orbital septum
Fig. 24 Splitting of the anterior and posterior lamella
muscle. Oftentimes, a lateral tarsal strip technique can retro-
place the globe posteriorly, and as a result, allow for some
anterior herniation of orbital fat. The herniated orbital fat or
813
Fig. 25 Completion of the lateral tarsal strip
Fig. 26 Opening the periosteal slot
pleated orbicularis muscle can be debulked by using a skin
hook for retraction. This should be done carefully so that the
lateral canthal sutures are not disrupted.
Closure begins by reforming the lateral canthal angle. The
lateral commissure is realigned along the lid margin using
814 R.D. Lisman and C.I. Zoumalan

Lateral orbital wall

periosteum

Tarsus

Fig. 27 Attachment of the strip to the periosteum

Fig. 29 Reformation of the lateral canthal angle

6-0 chromic suture (Fig. 29). The lateral skin is then closed
with either a 6-0 chromic or 6-0 silk suture. Sutures can be
removed in 5–7 days.

4.5 Over- and Under-resection

of Orbital Fat

Fig. 28 Resupporting the strip. Note that the Polydek suture is not vis-
ible after placement of the polydioxanone suture
4.5.1 Over-resection
Overzealous fat resection can result in a hollow, skeletonized
look that is aesthetically unappealing. Conservative resec-
tion is the best preventative measure. When over-resection
occurs, options for correction include fat transposition or
grafting, mid-face lifting and injection of fillers. In the
instance where enough fat remains in a different area of the
lid, fat transposition may ameliorate an isolated hollow. Free
fat grafts are often complicated by resorption of the addi-
tional tissue. Mid-face lifts may camouflage the defect by
enhancing the malar eminence. Periocular fillers, such as
hyaluronic acid gel, have an increasing role for filling hol-
lows. The ability to perform injections in the office setting is
Complications of Aesthetic Blepharoplasty and Revisional Surgeries
advantageous, but patients may experience lumps, bruising,
color change, and fluid accumulation. Additionally, the treat-
ment is temporary and patients must be counseled on the
need for recurrent injections [12]. In our experience, lateral
canthoplasty has a significant role in these instances since
posterior pressure on the globe will anteriorly displace any
remaining fat to soften the hollows.
4.5.2 Under-resection
Inadequate fat excision is easier to remedy. Patience is nec-
essary to assure resolution of edema and ecchymosis prior to
consideration of additional surgical resection.
Pearls to avoid inadequate fat resection are as follows:
• In the upper eyelid, the medial fat pocket is least accessi-
ble and may be inadequately addressed at the time of sur-
gery. The medial fat pocket can be identified as a distinctly
“whiter” fat than the central pad. Identification of the
medial fat is the first step towards its adequate resection.
• The lateral fat pocket is most commonly missed in lower
lid blepharoplasty and is seen postoperatively as a lateral
bulge (Fig. 30). There is a greater amount of connective
tissue septae covering this pad. Excision of the superficial
septae and fat allow additional prolapse of deeper fat with
mild pressure on the globe. It is common to re-herniate
the lateral pocket if canthoplasty is performed concur-
rently. Attention should be directed to re-evaluate the lat-
eral pocket if canthal tightening procedures are
performed.
4.6 Eyelid Crease Abnormalities
Symmetry and reformation of the upper eyelid crease may be
the single most important factor in a successful upper eyelid
blepharoplasty outcome [13]. The crease in women should
be higher than in men, allowing an adequate pre-tarsal reveal.
Additionally, a women’s crease is more sharply demarcated.
Fig. 30 A residual temporal fat pocket after transconjunctival blepha-
roplasty seen bilaterally (left worse than right eyelid)
815
In men, some fullness should be left in the upper lid to allow
the upper eyelid fold to cover the crease.
Patients with lid crease abnormalities should be evaluated
for ptosis. Unilateral ptosis can often result in brow elevation
and subsequent lid crease asymmetries.
4.6.1 Management
Careful preoperative marking and placement of an incision is
the first step to successful and natural crease retention. Eyelid
crease formation techniques have been described, and can be
useful in selected situations. While beyond the scope of this
chapter, supratarsal suture techniques involve securing the
skin to the fine threads of the levator aponeurosis to mimic
natural formation of a crease. Early eyelid crease abnormali-
ties should be followed. When persistent and cosmetically
unacceptable, crease re-formation can be performed surgi-
cally. When present, ptosis correction can be performed to
lower the eyebrow to a normal position. Once the lid is
brought to a normal position, the skin fold over the crease
can be left alone (to allow for redraping over the incision
site) or trimmed to match the contralateral side.
4.7 Malar Festoons
The best prevention of malar festoons is to diagnose them
preoperatively or to recognize patients who are at increased
risk. Patients with mild malar festoons should be questioned
about a history of thyroid disease, renal failure, chronic
sinusitis, allergies, and idiopathic edema. Patients who are
predisposed to fluid accumulation should be advised of the
risk of developing postoperative malar festoons. Preoperative
consultation with an internist is advised, as postoperative
care often involves systemic steroids and/or diuretics.
Patients who are at higher risk should be treated intraopera-
tively with intravenous steroids. Postoperative steroids (i.e.,
medrol dose packs) are useful. Furosemide (Lasix) 20 or
40 mg daily early in the postoperative course is helpful
(Fig. 31). With time, this agent can be replaced with a milder
diuretic, such as hydrochlorothiazide 50 mg per day. Medical
treatment is continued for 7–10 days.
While persistent malar festoons can be excised, the suc-
cess rate is low, as patients are again at risk for retained fluid.
If the underlying condition is systemic, eyelid surgery cannot
locally correct the problem.
4.8 Suture Tracks and Granulomas
Epithelial trapping can occur along suture tracks. If present,
suture tunnels can be unroofed with a fine needle or surgical
blade. Light cautery may also be applied. Granulomas can
also form around suture sites and also deep to the incision
816
a b
c d
Fig. 31 Pretreatment (a, c) and posttreatment (b, d) examples of malar
bags responding to diuretic therapy. Each patient was treated with furo-
semide and potassium replacement. Time alone may have produced the
sites. Often times, intralesional steroid injections may be
worthwhile, however, ultimate eradication of the suture
granuloma will require surgical excision.
Pearls that may help avoid this complication include the
following:
• Subcuticular suture closure with nonreactive suture (i.e.,
nylon)
• Early suture removal (day 4–6)
Very rarely, ophthalmic lubricant may be inadvertently
introduced into deeper eyelid tissues from a transconjuncti-
val surgical wound. This can result in encapsulation of the
ointment within the wounds, and subsequent cyst formation
that responds to excision (Fig. 32). Although this complica-
tion is extremely rare, physicians should keep in mind that
excessive amounts of ointment are unnecessary and may
result in its inoculation of the wound.
4.9 Hypertrophic Scarring
Keloid formation in the eyelid is exceedingly rare, but
hypertrophic scars may result from wound gapping during
healing. This usually responds well to massage and
pressure with steroid ointment. Injection of wound modu-
R.D. Lisman and C.I. Zoumalan
same result, but Lasix treatment plays a role in minimizing the stretch-
ing and attenuation of malar and lower eyelid skin
lators such as intralesional steroids and/or 5-fluorouracil
(5-FU) have been used in attempts to minimize scar for-
mation. Although they have a long track of safety, efficacy,
and mechanistic understanding, the use of such wound
modulators is an off-label use and adequate patient coun-
seling should be obtained prior to their administration
[14–17]. Caution is warranted with steroid injection around
the eyelids as its thin skin can allow visualization of the
steroid depot and hypopigmentation.
4.10 Dermal Pigmentation
Ecchymosis with prolonged resorption of blood contributes
to dermal pigmentation. Blood staining of the dermis can
take many months to fade. Expectant management is advis-
able. Trial and error treatment with hydroquinones can be
attempted to lighten the pigmentation after months of expect-
ant waiting.
4.11 Alopecia of Lashes and Chalazia
Patients with a history of blepharitis or chronic eyelid margin
disease, such as chalazia, are predisposed to alopecia of the
lashes. An incision site that is too close to the lash follicles
Complications of Aesthetic Blepharoplasty and Revisional Surgeries
a aritis) can produce lash loss. Recently, the FDA approved the
b
c
Fig. 32 This patient returned to her plastic surgeon after a lower eyelid
blepharoplasty complaining of recurrent fullness of each lower eyelid
(a). The lower eyelid masses appeared cystic and upon evacuation were
firmly encapsulated (b). Opening of the capsule and chemical analysis
of its contents revealed Lacri-Lube (Allergan, Irvine, CA) ophthalmic
ointment encapsulated from a foreign body reaction (c)
may result in lash loss. Additionally, overzealous cautery in
this region may damage follicles. However, if the follicle is
not destroyed, eyelashes will generally re-grow in 2 months.
Chronic edema in the setting of chronic inflammation (bleph-
817
use of Bimatoprost 0.03 % solution (Latisse: Allergan Inc,
Irvine, CA, USA) to increase eyelash length, thickness, and
darkness [18]. It may also provide a role in treating alopecia
of the lashes, although one study did not find it effective in a
small group of patients [19].
Chalazion formation is stimulated after surgery in
patients with a history of meibomian gland dysfunction or
anterior blepharitis. Pretreatment with eyelid hygiene will
minimize this risk. Patients should be advised to use warm
compresses, lid scrubs, and artificial tears. More severe
cases may respond to flax seed oil supplementation or oral
doxycycline. Surgical drainage can be performed if medi-
cal treatment fails.
4.12 Dry Eye Syndrome
True dry eye disease in a post-blepharoplasty patient can
only be diagnosed after ample time has been allowed for
resolution of common early and intermediate ocular sicca
symptoms. Regardless of approach and degree of tissue con-
servation, upper and lower eyelid blepharoplasty widens the
palpebral fissure. While generally well-tolerated, patients
with low levels of tear surface production or ocular surface
disease may not tolerate even a small amount of widening of
the fissures. For this reason, careful preoperative evaluation
should include the following:
• Assessment of dry eye symptoms
• History of dry eye disease, Sjogren’s syndrome or prior
refractive surgery
• Current use of lubricating eye drops and ointments
• Slit-lamp examination with fluorescein staining
• Basal tear secretion testing with Schirmer Strips (Eagle
Vision, Memphis, TN, USA)
Although not contraindicated, the surgeon should proceed
with caution when performing blepharoplasty on patients
with dry eyes, especially in cases of severe keratoconjuncti-
vitis sicca, where sight-threatening complications may arise.
Initial treatment of dry eye consists of ocular lubrication
with preservative-free artificial tears and ophthalmic oint-
ment. Failure of this treatment regimen should prompt oph-
thalmologic examination, with consideration of additional
anti-inflammatory eye drops or punctal occlusion.
Interestingly enough, a small subgroup of preoperative
patients with dry eyes and very heavy upper eyelids are actu-
ally improved by removal of excess skin [20]. In these cases,
the eyelashes are pushed inferiorly due to fullness. Normal
desquamation of the upper eyelid epithelium falls into the
palpebral aperture producing the symptoms of dry eye with-
out the physiologic findings of lacrimal, meibomian gland,
or goblet cell dysfunction.
818
4.13 Palpebral Fissure Asymmetries
Asymmetries of the eyelids are commonly noticed pre- and
postoperatively, and patient’s expectations should include
the fact that these asymmetries are always present. Eyelid
asymmetries can include the arch, height, curvature, and
width of the palpebral fissure, residual fat, dermatochalasis,
and eyelid crease positions. While gross disparities in surgi-
cal technique may result in iatrogenic asymmetry, adequate
patient expectations must be addressed preoperatively to
ensure that realistic expectations exist.
5 Summary
Although blepharoplasty surgery is a seemingly straightfor-
ward procedure, even the most gifted and fortunate surgeons
are destined to experience complications. Many of these can
be minimized by appropriate and thorough preoperative
evaluation, adequate patient and surgeon expectations,
meticulous and individualized surgical judgment, and early
postoperative recognition of unexpected side effects with
appropriate treatment. Developing a clinical framework
based on the timeline from surgery allows the astute surgeon
to recognize and manage these difficulties.
References
1. DeMere M, Wood T, Austin W (1974) Eye complications with
blepharoplasty or other eyelid surgery. Plast Reconstr Surg
53:634–637
2. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC (2004)
Incidence of postblepharoplasty orbital hemorrhage and associated
visual loss. Ophthal Plast Reconstr Surg 20(6):426–432
3. Teng CC, Reddy S, Wong JJ, Lisman RD (2006) Retrobulbar hem-
orrhage nine days after cosmetic blepharoplasty resulting in perma-
nent visual loss. Ophthal Plast Reconstr Surg 22(5):388–389
R.D. Lisman and C.I. Zoumalan
4. Koorneef L (1979) Orbital septa: anatomy and function.
Ophthalmology 86:876–880
5. Castillo GD (1989) Management of blindness in the practice of cos-
metic surgery. Otolaryngol Head Neck Surg 100:559–562
6. Campbell JP, Lisman R (2000) Complications of blepharoplasty.
Facial Plast Surg Clin North Am 8(3):303–327
7. Lowry JC, Bartley GB (1994) Complications of blepharoplasty.
Surv Ophthalmol 38:327–350
8. Baylis HI, Long JA, Groth MJ (1989) Transconjunctival lower eye-
lid blepharoplasty: technique and complications. Ophthalmology
96:1027–1032
9. McGraw BL, Adamson PA (1991) Postblepharoplasty ectropion:
prevention and management. Arch Otolaryngol Head Neck Surg
117:852–856
10. Ghabrial R, Lisman RD, Kane MA, Milite J, Richards R (1998)
Diplopia following transconjunctival blepharoplasty. Plast Reconstr
Surg 102:1219–1225
11. Demirci H, Hassan AS, Reck SD, Frueh BR, Elner VM (2007)
Graded full-thickness anterior blepharotomy for correction of
upper eyelid retraction not associated with thyroid eye disease.
Ophthal Plast Reconstr Surg 23(1):39–45
12. Goldberg RA, Fiaschetti D (2006) Filling the periorbital hollows
with hyaluronic acid gel: initial experience with 244 injections.
Ophthal Plast Reconstr Surg 22(5):335–343
13. Shorr N, Cohen MS (1991) Cosmetic blepharoplasty. Ophthalmol
Clin North Am 4:17–33
14. Taban M, Lee S, Hoenig J, Mancini R, Goldberg R, Douglas R
(2011) Postoperative Wound Modulation in Aesthetic Eyelid
and Periorbital Surgery. In: Massry, G. et al. (eds) Master Tech-
niques in Blepharoplasty and Periorbital Rejuvenation. Springer.
307–312
15. Fitzpatrick RE (1999) Treatment of inflamed hypertrophic scars
using intralesional 5-FU. Dermatol Surg 25:224–232
16. Ledon JA, Savas J, Franca K, Chacon A, Nouri K (2013)
Intralesional treatment for keloids and hypertrophic scars: a review.
Dermatol Surg 39(12):1745–1757
17. Gupta S, Kalra A (2002) Efficacy and safety of intralesional 5-fluo-
rouracil in the treatment of keloids. Dermatology 204:130–132
18. (2009) Bimatoprost 0.03 % solution (latisse) for eyelash enhance-
ment. Med Lett Drugs Ther 51:43–44
19. Roseborough I, Lee H, Chwalek J, Stamper RL, Price VH (2009)
Lack of efficacy of topical latanoprost and bimatoprost ophthalmic
solutions in promoting eyelash growth in patients with alopecia
areata. J Am Acad Dermatol 60:705–706
20. Vold SD, Carroll RP, Nelson JD (1993) Dermatochalasis and dry
eye. Am J Ophthalmol 115(2):216–220
Part VII
The Ear
 Otoplasty
Corrado Rubino, Francesco Farace, and Pietro Mulas
1 Introduction
The normal anatomy of the ear is certainly one of the aes-
thetic rules in force in the western culture. The malforma-
tions of the external ear or of other auricular structures may
be responsible for psychological traumata in the individuals
who are affected by them.
Several malformations of the ear may involve one or more
auricular structures. Undoubtedly, the most common malfor-
mation is that known as “bat ears”, also indicated by the scien-
tific community as “prominent ears” or “loop ears”, since they
produce a shadow which reminds the loops of terracotta pots.
Prominent ear is referable to a defect involving the auricle: in
an ear normally developed there is either lack or underdevelop-
ment of the anthelix, overdevelopment of the concha, and an
obtuse variation in the temporo-auricular angle. Such changes
may be present either isolated or associated to one another;
they may be expressed more or less severely and modify the
look of the face from both a frontal and a lateral view.
Less common, although equally important, are the
changes involving other structures of the external ear that are
referable to altered development affecting either the carti-
laginous framework or certain in tegumentary structures.
Such a category consists of the following malformations: the
first to be mentioned is “cup ear”, also known as “constricted
ear”; in this situation the malformation is expressed towards
the upper portion of the helix (more seldom of the scapha),
thus modifying the upper aspect of the ear which consequently
C. Rubino, MD (*)
FEBOPRAS, Dipartimento di Scienze Chirurgiche,
Microchirurgiche e Mediche, Università di Sassari, Sassari, Italy
e-mail: corubino@uniss.it
F. Farace, MD
Dipartimento di Scienze Chirurgiche, Microchirurgiche
e Mediche, Università di Sassari, Sassari, Italy
P. Mulas, MD
U.O.C. di Chirurgia Plastica, Dipartimento di Scienze Chirurgiche,
Microchirurgiche e Mediche, Università di Sassari, Sassari, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_58
appears flattened towards its bottom in both frontal and lat-
eral views. The look of the face is comparable with that
shown by a normal ear in which the helix of the upper third
is encircled by a string and then tied as a tobacco pouch.
Another malformation involving the cartilage of the auricle
is “Stahl’s ear” or “Satyr’s ear”, in which the anatomy is
altered by the presence of a third anthelix crus, with thicken-
ing of the upper crus; there is at times an associated spleni-
form transversal helix. The appearance is that of a general
narrowing of the scapha, with formation of an acute angle in
the upper portion of the helix, where normally there is a
smooth curve leading to the base of the helix. Even more
uncommon is “cryptotia”, a malformation in which the carti-
laginous upper pole is developed but is covered by scalp in
tegument. As a consequence, the upper auriculocephalic
groove is no longer present as well as the possibility of veri-
fying the presence of the upper auricular pavilion by direct
pressure on the skin.
There are also malformations involving the ear lobe that
may appear either under- or over-developed and may be
prominent, in certain cases, as compared with the tangential
plane of the ear pavilion. Such malformations may be iso-
lated or associated with other defects involving the ear
cartilage.
Microtia is a partial or complete (anotia) absence of the
ear structures, in which quite often there is only a lobule situ-
ated in a superior location whereas the tympanic channel is
absent. Such a malformation, which is more serious than
those previously described, requires a composite reconstruc-
tion in multiple surgical stages and it is not dealt with in this
chapter; the reader is advised to consult specialty treatises
which deal with the matter in detail.
Except for microtia and cryptotia, that are already mani-
fest at birth, the other malformations are generally diagnosed
between the third and the sixth year of life, when the ear
cartilage is nearly entirely developed. Therefore, the most
suitable time for a surgical correction should be around the
sixth year of life, even though in certain cases it is possible to
intervene at an earlier age.
821
822
The different phenotypic expression of the causes of ear
malformations, together with the analysis of the cartilage
quality, which may be more or less elastic, will address the
surgeon towards the most suitable surgical therapy in each
individual case. In fact, no universal procedure exists which
defines corrective otoplasty; more than 200 otoplasty tech-
niques together with a large number of variants have been
described from the early 1900s up to the present time.
2 History of Otoplasty Procedures
The history of reconstruction of the ear has ancient origins. In
the sixth century BC, Sushruta Samita [1] described the use of
a flap from the cheek for reconstructing the ear lobe. In 1597,
Tagliacozzi [2] described the use of retro-auricular flaps to
correct malformations of the ear. In 1845, Dieffenbach [3]
described the repair of defects, involving the mid 1/3 of the
ear, by means of an advancement flap. From 1845 on, the his-
tory of ear reconstruction is interwoven with that of the surgi-
cal correction of loop ears. In fact, reconstruction techniques
often undertake aesthetic otoplasty techniques and vice versa.
The basis for the surgical correction of prominent ears is
found in three procedures devised between 1845 and 1910:
excision of a lozenge-shaped area of retro-auricular skin,
resection of a cartilage segment of the concha, and reposi-
tioning of the anthelix fold. All the other methods are vari-
ants aimed at improving the aesthetic outcome and/or
stabilizing the results with time.
The first correction of prominent ears was suggested by
Dieffenbach (1845) in his famous book “Die Operative
Chirurgie” (The Operative Surgery), in which the reposition-
ing of the auricle was based on the removal of a skin ellipse
from the retro-auricular groove and its fixation to the mas-
toid bone by means of sutures. In the majority of cases tissue
elasticity allowed for the distention of the newly established
skin support, thus reproducing the deformity.
In 1881, Ely [4] reported two cases of correction obtained
following the removal of a cartilaginous segment from the
concha, thus providing a new surgical impulse towards oto-
plasty procedures.
The idea of correcting the malformation through the
reduction of the conchal cartilage was later on adopted and
improved by other authors, such as Keen [5] in 1890, Monks
[6] in 1891, and Morestin [7] in 1903.
Morestin gave an accurate description of the procedure, thus
spreading its clinical implementation. He claimed that the sin-
gle chondrotomy had to be wide, both for decreasing the ear
protrusion and for counteracting the elastic forces that would
keep the ear at a certain distance from the head. Such a simple
and effective procedure eliminates the retro-auricular groove,
and this results in a flat ear pavilion possessing a few protru-
sions and appearing as to be nearly attached to the head.
C. Rubino et al.
The third basic procedure was introduced by Luckett [8]
in 1910; he sensed that in the majority of the cases the mal-
formation is due to the absence of both the anthelix fold and
the two crura; therefore, the conchal concavity is continuous
with the triangular fossa. This originated the principle of
remodeling the anthelix. Luckett removes a crescent portion
of the posterior auricular skin at the level of the prospective
anthelix and excises an extended portion of cartilage around
the anthelix and its posterosuperior branch; then applies
some sutures to the residual edges.
The importance of this new technique was promptly
acknowledged; however, some variants were suggested, that
were aimed at improving the results. Such variants bear the
names of Mac Collum [9] in 1938, Mc Evitt [10] in 1947,
and Pierce [11] in 1947. The last author pointed out that the
main drawback of the method is the excessive thinning of the
anthelix fold due to surfacing of the resected cartilage edges
underneath the skin. As a consequence Mc Evitt suggested
the need for performing multiple parallel incisions on the
anthelix. In 1952, Becker [12] took up again the idea of per-
forming the incisions suggested by Mc Evitt; in addition he
associated to them some permanent sutures, that could force
the new anthelix into its new position, after rounding off its
contour. This idea was further refined and improved by
Converse [13] and in 1955, and was definitively standardized
and simplified in 1963 by Mustardè [14] who introduced the
use of mattress sutures between concha and scapha.
In the 1960’s a new idea was developed to force cartilage
into a more anatomical position simultaneously to the above-
mentioned techniques that suggested parallel cartilaginous
incisions and sutures on the various segments of the ear car-
tilage. This at weakening the lateral aspect of the cartilage by
means of micro-incisions (defined also as cartilage scoring)
along the anterior axis of the new anthelix. The significant
difference consists of the fact that in this technique the ear
cartilage is not sectioned in its full thickness, thus ensuring a
more harmonious and rounded contour of the new anthelix.
The principle at the basis of the technique of cartilage weak-
ening derives from the studies carried out on the costal carti-
lage by Gibson and Davis [15] in 1963. It was simultaneously
introduced in the treatment of prominent ears by Chongchet
[16] and Stenstrom [17] in 1963.
The theory of anterior scoring of the cartilage of the ear,
suggested by Chongchet and Stenstrom, was subsequently
improved, as both the posterior and the anterior routes of
approach were modified [18–20] as well as the modality for
performing the chondrotomies by using various surgical
instruments.
Some authors [Pancrazi [22] in 1999] have more recently
modified the techniques of cartilage weakening by adding
intracartilaginous mattress sutures and by extending the
weakening to the upper third of the ear also [Rubino [23] in
2005].
Otoplasty
3 Outline of Embryology
The knowledge of the embryology of the ear is useful in
order to understand that no relationship exists between the
external ear and internal ear. As a consequence, a strong
reassurance can be given to a parent worried whether his or
her child, presenting with a congenital malformation of the
external ear pavilion, could show hearing disturbances also.
The external ear originates from six ectodermal-mesodermal
tubercles that grow, around the fortieth day of embryonal
life, from the superior margin of the first branchial groove
and from two branchial arches that contain such a groove.
Three of these tubercles are located anteriorly and belong to
the first branchial arch, whereas the remaining three tuber-
cles are located posteriorly and belong to the hyoid arch. The
tragus and helix derive from the anterior tubercles; the helix
lengthens backward and downward until it encloses the three
posterior tubercles; the latter will form the anthelix, concha,
scapha, and lobule.
The cartilages derive in part from the cartilage of the pri-
mordial external acoustic meatus, whereas the muscles origi-
nate from the hyoid arch. The ear shows an apparently regular
morphology as early as the fourth month of intrauterine life.
The internal ear has a different ectodermal origin and
appears to be partially developed at the third gestational
week and then reaches maturation at the third month of
gestation.
4 Normal Anatomy
Exact knowledge of regional anatomy is fundamental in
order to planning a surgical procedure suitable for the differ-
ent morphologic needs.
The ear is made up mainly of skin and cartilage; it has an
oval shape with an upper extremity enlarged, transversely
flattened, and fixed to the lateral aspect of the skull, from
which it is separated by a 20–25° angle. From a topographic
standpoint the ear pavilion is located close to the temporo-
mandibular joint, in front of the mastoid bone, underneath
the temporal region.
In order to be within normal limits, the site of implant of the
ear should be located, in the frontal plane, between a line traced
through the eyebrow and a line traced through the free margin
of the nasal ala. The greater axis of the ear measures 5.5–7 cm
and has an oblique posterior to anterior course; its normal
width is around 60 % of its length, namely, 3–4.5 cm. The car-
tilage thickness oscillates from 0.5 to 1.5 mm and provides the
framework of the ear (with the exception of the lobule); it gives
elasticity to the ear as well as enough stiffness to support the ear
and to maintain its wavy morphology. Cartilage’s elastic prop-
erties are the mainstay of modern otoplasty techniques. The
823
cartilage is lined with perichondrium, and it is particularly
thick and resistant in its posterior aspect, thus ensuring a satis-
factory traction to surgical ligatures (Fig. 1).
4.1 Anterior or Lateral Aspect (Fig. 1)
• Helix: it draws an eccentric ring with an anterior cavity. It
starts from the posterior portion of the concha (crus of
helix), proceeds obliquely upward and forward, being sep-
arated from the tragus by a large notch, and ends with a
tapered extremity (tail of helix). At the level of the tragus
it shows a prominence (spina of helix); in its posterosupe-
rior portion has a rounded or triangular eminence, more or
less pronounced (auricular or Darwin’s tubercle). The
helix supports the lower one third of the ear pavilion.
• Fossa of the helix: it separates the former crest from the sub-
sequent one, thus showing on sections a semicircumferential
appearance. It forms a slight protrusion on the medial side.
• Anthelix: it originates at the level of the tail of the helix,
being separated from it by means of an incisura, and goes
over the concha. Its anterior margin is divided into two
branches (anthelix crura) that bound the navicular fossa (or
triangular fossa); the horizontal inferior branch ends at the
level of the helix and generates a protrusion at the level of
the concha; the superior branch, oblique upward and for-
ward, ends in the fossa of the helix. The anthelix is impor-
tant for determining the morphology of the ear pavilion.
• Concha: it forms a funnel-shaped depression measuring
around 20–25 mm in height and 15–18 mm in width. It is
divided into two uneven portions, a narrow upper part
(cymba) and a wide lower part (cavum) that continues
directly into the external auditory meatus.
• Antitragus: it is the downward and forward extension of the
anthelix; it is separated from the anthelix by a depression.
It has an ovoid shape and is located behind the tragus.
• Tragus: it is situated anteriorly with respect to the external
auditory meatus; it is separated from the helix upward by a
large anterior groove of the ear (incisura anterior auris) and
downward (from the subsequent protrusion) by a rounded
depression, that is the notch of the concha (incisura intertrag-
ica). The tragus has a triangular shape, with an anterior base;
its free apex, turned backward and outward, shows two pro-
trusions (the upper protrusion constitutes Helix’ tubercle).
4.2 Medial or Posterior Aspect
The medial or posterior aspect is oriented forward and
medially towards the cranial wall; it constitutes the route of
the surgical approach most commonly used; its anterior one
824
Rear branch of the
temporoparietalis muscle
Helix
Scapha
Auricular tubercle
Anthelix
Incisura anterior
Cavum conche
Rear auricular muscle
Antitragus muscle
Ear lobe
Fig. 1 Normal anatomy of the ear including muscular structures
third, for 4 cm in height and 2 cm in length, adheres to the
cranial wall and corresponds anteriorly to the opening of
the auditory canal. In this area the previously described
structures are visible with reverse and attenuate patterns.
The most manifest sign is the conchal convexity (eminentia
conchae), surrounded by a depression corresponding to the
anthelix; which outlines a cavity, the anthelix fossa. The
two branches resemble ropes that isolate a protrusion, the
triangular eminence, which is the reverse image of the
navicular fossa. The groove corresponds to the inferior
branch of the anthelix and appears as a narrow though
marked track, named transversal groove. Posteriorly the
skin is thick, firm and slides on the cartilage through a layer
of cellular tissue relatively loose. On the contrary, the skin
covering the anterior surface is very thin; it is quite adher-
ent to the perichondrium and traces minor reverse struc-
tures, with the exception of the tragus and the anterior area
of the helix root.
Lobule: it constitutes the lower one third of the ear pavil-
ion. It hangs from the concha, while its inferior extremity
forms a free semicircular edge. The lobule is made up with
two thick skin layers, separated from one another by an
abundant cellular adipose tissue lacking any cartilaginous
support.
C. Rubino et al.
Temporoparietalis muscle
Musculus helicis major
Anthelix crus
Triangular fossa
Conchae
Musculus helicis minor
Helix crus
External acoustic meatus
Muscle of tragus
Tragus
Antitragus
Intertragic notch
Anti-intertragic fissure
Ligaments: the external ligaments fix the ear pavilion to
the temporal bone. The ligaments are divided as follows:
• The anterior ligament, going from the spine of the helix
and the tragus to the apophysis of the zygomatic bone. Its
role as a fixing structure is undeniable and its section
requires a repair procedure in order to prevent dislocation.
The posterior ligament is probably less important from a
functional standpoint; it connects the internal aspect of
the concha to the mastoid bone.
• The intrinsic ligaments are not individually important
since they are joining expansions deriving from the peri-
chondrium. At times they either fill some cartilaginous
notches or exert some traction on certain portions of the
cartilage, thus contributing to its shape.
Muscles: they lay on the ligaments. The extrinsic muscles
orient the ear, are very thin or poorly active. The following
muscles are found: the superior auricular muscle, from the
temporal aponeurosis upward and the internal portion of the
ear pavilion where it is inserted at the level of the little anthe-
lix fossa; the anterior auricular muscle, running from the epi-
cranial aponeurosis to the spine of the helix and to the anterior
edge of the concha; the posterior auricular muscle consists of
Otoplasty
Fig. 2 Arterial, venous, and
nervous supply of the normal ear
two or three bundles and unites the base of the mastoid
apophysis to the mid portion of the conchal convexity. In
those techniques in which the cephalo-conchal angle is going
to be repositioned, the latter muscle is either repositioned or
partially excised in order to deepen the conchal cavity.
From a surgical standpoint the intrinsic muscles are very
slightly important; they are actually virtual in man. The fol-
lowing muscles should be mentioned: the great and the small
muscles of the helix, the muscles of the tragus and of the
antitragus, the transversal and oblique muscles located on
the internal surface.
4.3 Neurovascular Supply
Blood supply: the arterial blood supply comes from the inter-
nal carotid artery and is characterized by two systems
(Fig. 2). An anterior peduncle formed by three anterior auric-
ular arteries, branches of the superficial temporal artery, that
are in detail an anterosuperior branch for the anterosuperior
quadrant of the ear pavilion, an anteromedial branch for the
concha and the root of the helix, and an anteroinferior branch
for the tragus and the lobule. A posterior peduncle arising
from the posterior auricular artery is more important than
that previously mentioned, inasmuch as it gives origin to two
different branches supplying the entire posterior aspect and a
portion of the anterior aspect of the ear pavilion through
some perforating vessels that encircle the helix. Such a rich
blood supply explains the relatively hemorrhagic pattern of
825
Front auricular arteries
Auriculotemporal nerve
Superficial temporal artery
Great auricular nerve
Rear auricular artery
surgical procedures; at any rate, the numerous anastomoses
allow to perform any type of incision.
The veins are distributed over two territories:
• An anterior territory, where the superficial veins drain into
the subcutaneous plexus of the cheek, whereas the deep
veins drain into the temporal vein (upward) and into the
deep veins of the posterior parotid gland (downward).
• A posterior territory, whose superficial veins communicate
with the superficial occipital veins; the posterosuperior
veins drain into the deep temporal vein, the middle and the
inferior veins join together in a constant posterior arch that
ends into the deep veins of the parotid gland. Some veins
communicate with the veins of the mastoid region.
Nerve supply: the sensorial innervation is provided by
three nerves:
• The auriculo-temporal nerve, branch of the trigeminal
nerve, that supplies the ascending portion of the anthelix,
and the tragus;
• The great auricular nerve, a posterior branch of the super-
ficial cervical plexus, that supplies the internal aspect of
the ear pavilion, the lobule, the antitragus, the posterosu-
perior portion of the helix, the anthelix, the scapha, the
external acoustic meatus, the retro-auricular groove, and
the concha; and
• The sensory branch of the facial nerve, that supplies the
area formed by the concha and the external acoustic
826
meatus; the latter is provided with an additional nerve
supply from the auricular branches of the vagus nerve and
from the glossopharyngeal nerve [25].
5 Anatomic Variations and Associated
Aesthetic Deformities
Certain angles between the ear and the skull are expressed by
well-codified values. The knowledge of such values as well
as the analysis of their prospective deviation may facilitate
both the diagnostic approach and the surgical planning.
These angles complement the knowledge of the normal
human anatomy of the external ear.
• Cephalo-conchal angle: it is between two planes, one of which
runs through the mastoid bone and the other is tangential to the
concha. Its normal value oscillates between 80° and 90°. An
increase in the angle over 10° produces an aesthetic malforma-
tion. The causes may be an altered junction between external
meatus and concha, or a change in the cartilage elasticity at the
level of the inferior arm of the antihelical bifurcation.
• Scapho-conchal angle: it is responsible for helix angula-
tion over the anthelix. Its value lies between 85° and 90°;
the angle is delimited by scaphal and conchal tangential
planes. Its value must be maintained when either recon-
structing or repositioning the anthelix. In fact, one of the
typical deformities of loop ears consists of a widening of
this angle up to approximately 175°. The clinical diagno-
sis of such a variation is easily achieved by pressing with
the examining fingers on the patient’s helix, thus forcing
the scapho-conchal angle within normal values.
• Cephalo-auricular angle: it is contained between the mas-
toid bone and the posterior edge of the ear pavilion; its
apex lies in the retro-auricular groove, and its value oscil-
lates between 20° and 30°. This angle is directly influ-
enced by changes occurring in the two angles previously
described; in addition it is in relationship with the concha.
In fact, conchal hypertrophy increases the distance
between the ear pavilion and mastoid bone; this is typical
of flap ears. The physical examination with digital pres-
sure on the helix cannot correct such a deformity; this sug-
gests, therefore, a different corrective surgical strategy.
Angulometry and physical examination aimed at discov-
ering any supernumerary structures, such as the third crus in
Satyr’s ear, or the lack of certain segments in the ear pavilion
such as that occurring in loop ears (absence of anthelix) or in
cup ears (absence of upper one third cartilage), must lead to
an accurate diagnosis of the different malformations in order
to plan surgical therapy to correct of the defect without per-
forming any secondary procedures.
C. Rubino et al.
6 Aesthetic Otoplasty: Surgical Therapy
Multiple techniques as well as numerous variants exist in
order to solve the different phenotypic expressions of loop
ears. It is impossible to outline all of them in this article;
therefore, only those more commonly used at present are
hereinafter described, inasmuch as their knowledge appears
to be necessary for completing the technical education of
every plastic surgeon.
6.1 Mustardè Technique (Fig. 3)
This technique, described by JC Mustardè in 1963, is used
mainly for correcting the prominent upper one third of the
ear, where it is necessary to restore the antihelical fold. It is
indicated in instances of mild to moderate defects particu-
larly in children, in whom the cartilage is mobile and can be
easily manipulated.
Preoperative planning is performed by pressing with the fin-
gers on the helix in order to recreate the missing folds. Then
several pairs of dots are drawn on the concha and on the anterior
aspect of the anthelix. By using several 25-gauge needles dipped
in ink, the dots are reproduced on the posterior aspect of the ear
pavilion. Such dots indicate the position in which the conchal-
scaphal mattress sutures are going to be applied. On the poste-
rior aspect of the pavilion, immediately internally to the two
rows of drawn dots, a lozenge-shaped skin area is selected and
then removed deeply down to the cartilage; all the soft tissues
and the perichondrium are also removed. The skin surrounding
the removed lozenge-shaped skin flap is then going to be
detached enough to expose the dots where the mattress sutures
are going to be applied, using 4-0 polyester stitches, in both
sides of the antihelical apex. In applying such sutures the full
thickness of the cartilage is passed through, being careful to
include the external perichondrium at a strictly subcutaneous
level. Usually two to three sutures are adequate; they must be
tied in a progressive order, starting from the medial one, then
working on the superior one, and finally tying the inferior one,
till the involved prominence is reached. Then the skin is closed
with a continuous intradermal suture or with an overcasting 4-0
nylon suture. Frequently, undercorrection is the final outcome.
6.2 Furnas Technique (Fig. 4)
The technique suggested by Furnas [26] in 1968 is used in
children and youngsters, whose cartilage is supple and soft,
being therefore suitable for molding through the use of mat-
tress sutures. This technique corrects the upper two thirds of
the ear pavilion when a well-defined fold of anthelix is pres-
ent; otherwise it may be associated with Mustardè technique
in order to improve the results.
Otoplasty 827

a b c

d e f

Fig. 3 The Mustardè otoplasty technique. (a, b) Preoperative markings of the anterior auricle. (c) Preoperative markings, posterior view. (d)
Mattress sutures positioned on the posterior aspect of the ear cartilage. (e) The sutures are tightened to recreate the anthelix. (f) Skin closure

A lozenge-shaped wedge of skin is excised from the retro-
auricular groove. The muscles and the posterior auricular liga-
ments are removed in the depth of the surgical wound, down to
the perichondrium lining the posterior auricular cartilage. At
this stage it is necessary to pay special attention to preserving
the branches of the great auricular nerve. The technique antici-
pates the excision of a portion of the fascia covering the mas-
toid bone. In such a way the concha, in its new location, has a
greater space posteriorly in the absence of soft tissues. The
conchal cartilage is sutured to the portion of fascia which had
been left in place. Two or three 4-0 polyester mattress sutures
are enough; they must pass through the full thickness of the
conchal cartilage and attention should be paid in order to
enclose the perichondrium anteriorly underneath the skin.
Similarly to the Mustardè technique, the sutures should
be tied in a progressive fashion, namely the middle one at
first, then the superior one, and finally the inferior one. The
skin is approximated with a continuous intradermal suture or
with an overcasting 4-0 nylon suture. Some of the most com-
monly used variants, such as the variant suggested by Gibson,
contemplate weakening the cartilage of the anterior aspect of
the anthelix; such a weakening is done by means of specific
surgical instruments (otoabrader, diamond drills, surgical
forceps, etc).
828
6.3 Converse-Wood-Smith Technique
(Fig. 5)
In 1971, Converse and Wood-Smith described a technique
contemplating the section of the conchal cartilage followed
by its tubularization. Such a technique is indicated in the
treatment of severe loop ears at any age, being satisfactorily
suitable for poorly elastic cartilages, such as in adults pre-
senting with absence of helical fold, excessively developed
concha and on oblique conchal-scaphal angle.
a b
c
d
Fig. 4 The Furnas otoplasty technique. (a, b) Conchal repositioning
(a, preoperative angle, b, postoperative conchal angle). (c) Posterior
skin excision. (d) Posterior cartilage and auricular muscle exposure.
C. Rubino et al.
This procedure is carried out through the manipulation of
ear pavilion: a medially directed pressure is exerted on the
helix and a few lines are drawn on its anterior surface. The
drawing identifying the new anthelix fold is a line that encir-
cles the superior crus on three sides and includes the upper
edge of the superior crus, the upper edge of the triangular
fossa, and the line indicating the junction between scapha
and helix.
A line is then identified and traced along the conchal rima;
it represents both the reference point of the corrective maneu-
(e) Suture positioning. (f) Cartilage ellipse excision. (g–i) Suture tight-
ening and cartilage repositioning
Otoplasty
e f
g h
Fig. 4 (continued)
vers involving the conchal-scaphal angle and the excision of
the conchal excess. The lines drawn on the anterior aspect
must be replicated on the posterior aspect. For such a step we
use straight needles that are passed through the full thickness
of the ear pavilion. We are able, therefore, to identify posteri-
orly the skin area to be removed, together with the underlying
soft tissues, including both cartilage and perichondrium. Full-
thickness cartilage incisions are carried out along the edges of
the prospective anthelix; attention is paid to preserve the skin
of the anterior surface. The upper horizontal incision should
be incomplete: a bridge of intact cartilage should be left at
both extremities, without reaching the vertical incisions. Then
the skin is detached up to the rim of the helix.
The new anthelix is realized by tubularizing the cartilage
between the incisions, using interrupted 4-0 polyester
sutures. When the cartilage is particularly thick or refractory
829
i
to tubulization, it may be thinned by performing a scoring on
its posterior aspect by means of either a rotating brush or a
few slight superficial incisions. The sutures should be tied
concomitantly; enough tension should be exerted to ensure a
satisfactory bending of the anthelix. The concha is remod-
eled by removing a crescent portion of it; it is then attached
to the new anthelix by additional plain sutures. The limit of
this technique consists in obtaining an excessively elevated
antihelical ring together with a reduction in the scapha; at
times an un-natural shape of the ear may be the outcome.
6.4 Chongchet Technique
The technique described by Chongchet in 1963 is aimed at
reconstructing the antihelical fold by incising the cartilage;
830
this facilitates its remodeling through an anterior scoring
maneuver. We continue to apply Keith’s method of trans-
fixion stitches in order to position the anthelix backward;
we are able to discover its position by manipulating the ear
pavilion.
A lozenge-shaped area of skin is excised from the poste-
rior surface; soft tissues are removed until the underlying
cartilage is exposed. Then a full-thickness incision is made
a b
d e
Fig. 5 The Converse-Wood technique. (a–e) Preoperative markings. (f) Anthelix marking with needle. (g–i) Cartilage incisions. (j) Conchal angle
repositioning. (k, l) Sutures tightening with anthelix reshaping
C. Rubino et al.
in the cartilage along the line that joins the dots marked by
the needles; subsequently, the cartilage is dissected from the
anterior aspect of the skin. The incision is then prolonged
horizontally, towards the base of implant of the ear in order
to obtain a cartilaginous flap measuring a few millimeters,
while the perichondrium is maintained intact. On the anterior
aspect of the cartilaginous flap a scoring is carried out by
using partial thickness parallel incisions that follow the
c
f
Otoplasty 831

g h i

k
l

Fig. 5 (continued)
832 C. Rubino et al.

greater axis of the ear. As a result of such anterior chondroto-

mies, the weakened cartilage tends to bend spontaneously,
thus recreating the anthelix fold.
Similarly to the previously described techniques, even
in this procedure the skin is approximated by a few 4-0
nylon sutures, applied either as a continuous intradermal
suture or as an overcasting suture. The Chongchet tech-
nique provides a natural curve for the anthelix but exposes
to the risk of recurrences at the level of the upper one third
of the ear.

6.5 Scuderi Technique

The posterior auricular cartilage is exposed from the anthe-

lix crus to the posterior auricular muscle through resection
of a small elliptical-shaped area of skin from the posterior
aspect of the ear. The muscle is then isolated; special atten-
tion should be paid at its insertion to the conchal ponticulus.
A lozenge-shaped partial resection of the concha is carried
out, inclusive of the quadrangular segment to which the
muscle is inserted. A chondromuscular flap is then prepared
which is moved forward and sutured laterally with 4-0 nylon
sutures in order to create the cephalo-auricular angle. At this
stage the correction of any possible deviation of the main
axis can be carried out by repositioning the muscle in a
more caudal or cranial location, so that the entire ear is
rotated in a sagittal plane.
The correction of the anthelix is obtained as follows: after
seeing the new fold by means of transfixion needles, in the
presence of average or moderate hypoplasia, anterior scoring
with a needle is carried out on the cartilage which is
approached through a small posterior incision; a few 4-0
nylon mattress sutures are then applied. On the contrary,
when the absence of the anthelix is severe, two incisions are
performed along the lines drawn on the posterior aspect of the
ear cartilage; the strip of rectangular cartilage adherent to the
anterior perichondrium is isolated by undermining the lateral
segments of its anterior aspect. Such a procedure mobilizes
the cartilage flaps, that are then sutured in order to recreate
the anthelix.
6.6 Author’s Favorite Technique:
Technique Derived from
the Chongchet Technique
Granted that no technique exists which is suitable for all loop
ears and that it is therefore essential to know all the corrective
principles applicable to the ear in order to achieve the best
result in behalf of any individual case. The authors describe in
detail the technique that they perform and from which they
obtain the most satisfactory and long-lasting results. Such a
Fig. 6 The modified Chongchet technique: anterior cartilage under-
mining, intraoperative view
technique may be used in most instances of anthelix absence
or underdevelopment. The technique is a modified variant of
Chongchet technique (Figs. 6, 7, 8, and 9).
The cephalo-auricular angle, the anthelix development,
and the cartilage quality must be evaluated at first. Then the
line along which the anthelix shall be created is obtained by
pressing the ear pavilion against the skull.
The patient lies down with the head turned towards one
side. The head rests on a silicone ring that allows for the ear
pavilion to be unaffected by the weight of the skull during
the procedure. The hair, surrounding the ear pavilion is held
in place by transparent sterile strips of adhesive tape, that
are applied in such a way as to allow only the exit of both
the external ear and the neighboring hairless area. A wisp
of cotton wool is inserted into the external meatus so that
no disinfectant shall penetrate the tympanic chamber; then
disinfection of the operative field is carried out.
Approximately 8 ml of a 0.5 % mepivacaine solution with
1:200,000 epinephrine are injected into the area between the
helix and the hairline, at the level of the anterior auricular
muscle, in order to block auriculo-temporal nerve pathways;
the anesthetic infiltration continues along the cutaneous area
Otoplasty
Fig. 7 The modified Chongchet technique: anterior cartilage scoring
and folding of the cartilage flap, intraoperative view
over the temporozygomatic joint and then posteriorly to the
middle of the retro-auricular groove, in order to block nerve
conduction in the great auricular nerve.
A second infiltration is carried out at the level of the ear
lobe and proceeds anteriorly towards the tragus and posteri-
orly along the above-mentioned groove joining the previ-
ously anesthetized area. The third area to be anesthetized
involves the concha, just outside the external meatus where a
few nerve endings, derived from the vagus nerve, are present.
The authors prefer to inject also 1 ml of anesthetic solution
along the skin area that shall be removed posteriorly, at the
level of the anthelix and at the anterior aspect of the ear
pavilion, always at the level of the anthelix.
The auricular pavilion is pressed in order to bring into
evidence the anthelix line and its track; three 21-gauge nee-
dles, dipped into a vital coloring agent, are inserted at full
thickness between the helix and anthelix. In such a way a
broken line is evidenced on the posterior auricular skin and
inside the cartilage, where the line ends. The skin excision at
the posterior aspect of the ear pavilion has an hourglass
shape with a winding path, measuring from 3 to 4 cm long
and 0.8 cm wide. In such a way a prospective tense cicatriza-
tion with a hypertrophic outcome can be prevented. The tis-
sues are first dissected; then the cartilage is exposed and
833
incised in its full thickness along the broken line, so that a
cartilage flap is obtained. The cartilage is then dissected
from the tissues of the anterior aspect of the ear pavilion and
weakened by means of partially thick parallel incisions made
along the greater axis of the anthelix. In addition, the carti-
lage is incised in a perpendicular fashion at both its upper
and its lower one third, in order to obtain a smoother curva-
ture of the cartilage itself. As a consequence, the cartilage
bends spontaneously. The stability of this cartilaginous flap
is achieved by 2 or 3 plain 4-0 white Vicryl stitches, whose
ties must be located inside the area of rounding (in such a
way the tie is prevented from producing a granuloma). To
avoid a secondary “telephone ear” the anterior dissection is
continued also in the area located close to the helix in the
upper one third of the ear. A scoring of this area is carried out
in order to weaken it and to force it in reproducing the move-
ments of the previous rounding maneuver. In such a way the
stitches suggested by Furnas are no longer necessary. As a
consequence, the risk of suture granulomas is avoided.
In addition to restoring the anthelix, when it is necessary
to reduce the prominence of the concha, the authors proceed
with the resection of a full thickness semilunar portion of the
cartilage from the central part of the concha through the
exposure already gathered for the posterior aspect of the ant-
helix. When the conchal angle is not excessively prominent,
the authors proceed with the partial resection of the retro-
auricular muscle; the latter structure is then repositioned so
that a larger space is obtained for the concha; as a conse-
quence the angle is reduced in relation to the plane going
through the mastoid bone. The skin is approximated with
four 4-0 nylon mattress sutures, whereas its lower portion is
left open for approximately 0.5 cm in order to facilitate the
prospective drainage of any residual blood.
The surgical dressing contemplates the compression of
the conchal area, the triangular fossa and the scapha by
means of greasy gauze. Then the ear is covered with sterile
cotton wool and with superimposed gauze. An elastic ban-
dage will maintain the dressing in place for 7 days.
7 Miscellaneous Defects
7.1 Cup Ear: Surgical Therapy
Tanzer defined cup ears as malformations due to constriction
of the external ear. Such defects present with different pat-
terns that vary from an absence of the upper one third of the
anthelix, with consequent collapse of the helical apex
towards the external aspect of the ear pavilion, to the reduc-
tion in cartilaginous and soft tissues of the scapha. The treat-
ment differs according to the degree of the severity; as a
consequence, the correct diagnostic classification is essential
in order to avoid any error at the time of surgical planning.
834 C. Rubino et al.

a b c

d e
f

Fig. 8 The modified Chongchet technique. (a) Preoperative aspect. (b) cartilage scoring and flap folding with stitches. (g) Upper posterior ear
Anthelix needle markings. (c) Posterior skin excision. (d) Posterior car- third undermining in order to prolong the cartilage scoring
tilage exposure. (e) Posterior cartilage flap incision. (f) Anterior
Otoplasty
Fig. 9 The modified Chongchet technique: preoperative aspect (upper
fig.) postoperative aspect (lower fig.)
Surgical therapy varies according to the different
anatomical-clinical situations. In the event that the malfor-
mation is mild, the tissues are well preserved and the change
involves only the rim of the helix without affecting the full
height of the ear pavilion (which should be always compared
with the contralateral ear pavilion), the surgical procedure
should be as follows: the soft tissues are incised and dis-
sected in order to expose the helical cartilage. In such a way
it is actually possible to detect the amount of helical cartilage
bending towards the scapha. With the help of a vital coloring
agent the new rim of the helix is drawn, according to the pat-
tern thought to be the most appropriate, and then the exceed-
ing amount of cartilage is removed with a knife.
When the difference with the contralateral ear is less than
1 cm, the exceeding helical cartilage is used as a medially rotated
flap, with a pivot stitch applied at the base of the helix, to be
repositioned at a higher level and to be sutured at the scapha.
In both situations described above, cutaneous closure is
then carried out and the helix is steadied in place by means
of a compressive dressing as well as transfixion sutures.
835
At this point we would like to remind readers that in cer-
tain situations the clinical diagnosis may need to be reformu-
lated at the operating table. In other words, often the cartilage
of the helix may be accurately assessed only when it is
exposed and dissected from the soft tissues. Therefore, it
would be appropriate to go into the operating room with sev-
eral planned surgical solutions in mind.
When the constriction is such as to originate a difference
in height over 1.5 cm as compared with the healthy contralat-
eral ear, the correction may be considered similar to that per-
formed in instances of microtia. Therefore, the surgical
procedure shall be carried out by using implant or flap tech-
niques in order to add both cartilage soft tissues.
7.2 Stahl’s Ear: Surgical Therapy
Stahl’s ear or Satyr’s ear is characterized by a supernumerary
groove crossing the scapha; the anthelix appears as a trifur-
cated structure that constrains the helix in a “spiked” unnatu-
ral position. In view of this aspect, the denomination of
“Spock’s ear” or “Vulcan ear” has been recently suggested,
since these malformed ears remind one of a famous science
fiction television series.
The diagnosis is easily made and the treatment is aimed
first of all at eliminating excessive cartilaginous tissue that
forms the third crus, and then at completely remodeling the
anthelix whenever it is necessary. Multiple techniques can be
employed, in relation both to the degree of development of
the anthelix and to the surgeon’s preference. The authors pre-
fer to carry out a modified Chongchet technique in instances
of this malformation also.
7.3 Cryptotia: Surgical Therapy
In this quite rare malformation the anthelix appears to be
normally developed although it is probably anchored to the
temporal region. As a consequence the temporal scalp par-
tially includes the upper one third of the ear. Even in this
malformation the diagnosis is easily made and the recon-
structive difficulty often involves only teguments without
affecting ear cartilage.
In fact, the rationale of the therapy is addressed to find
some tissues that are able to allow for the release of the upper
one third of the ear pavilion, thus creating a physiologic
cephalo-auricular angle.
The most commonly employed surgical techniques for
the treatment of cryptotia are the full-thickness autolo-
gous skin graft in instances of significant lack of tissues,
the “Z” otoplasty or the “V-Y” advancement flaps in less
serious cases.
836
7.4 Prominent Lobes: Surgical Therapy
In certain settings the lobe protruding from the auricular plane
may be considered as a malformation. Seldom such a defect is
congenital, whereas it results more often from either a protru-
sion of the lower one third of the ear or an overcorrection of its
upper two thirds. Therefore, it is a condition resulting from a
surgical error made during an otoplasty procedure.
The most commonly used corrective method is that
improved by Wood-Smith, also known as “fishtail excision”.
It is easily performed; it contemplates the excision of a retro-
auricular lozenge-shaped area; the excision then continues as
a “V” on the posterior surface of the lobule. After perform-
ing the incision, the lobe is pressed against the skin of the
mastoid bone and a mirror impression of the “V” is obtained
on the skin of the mastoid bone; in addition a fishtail or a
“W” impression is obtained between the ear lobe and mas-
toid bone. Then a soft tissue excision is carried out; finally,
the lobe is partially sutured to the mastoid region. The out-
come is both a partial reduction and a repositioning of the ear
lobe that appears to be normal.
8 Complications
The immediate complications [27] are classified under three
types:
Hematoma. It is due either to an active bleeding or to a slow
hemorrhagic leakage occurring in the earliest postopera-
tive period. The symptom is usually a sharp pain develop-
ing a few hours following the surgical procedure. Prompt
treatment should be carried out, consisting in the com-
plete removal of the clots present in the operative field as
well as in the accurate control of hemostasis. If left
untreated, there is the risk of development of either a
recurrence or a much more serious infection.
Infection. It is a rare but possible event. It becomes manifest
through its typical signs and symptoms: erythema, edema,
secretion, itching and/or pain. The pathogenic agents usu-
ally are staphylococcus or streptococcus. More seldom
the cause is Pseudomonas. Intravenous antibiotic therapy
for a prolonged period and at high dosages is mandatory
in order to prevent progression of the condition towards
chondritis, cartilage loss, and secondary deformities.
Chondritis. It is a very rare complication since it occurs only
when the infection is undiagnosed. Under such circum-
stances, the only feasible solution consists in the surgical
revision of the operative area and its debridement.
Delayed complications are generally defined as late
deformities. Actually, within 6 months from the surgical pro-
cedure, certain residual deformities may become manifest;
C. Rubino et al.
they are more or less significant and are the result either of an
improper technique used in that particular case or, at times,
of the surgeon’s inexperience. The accepted treatment in
such situations consists of performing a second otoplasty.
9 Non-operative Treatment of Ear
Pavilion Malformations
It is now important to recognize that in the treatment of the
malformations previously described it is possible to obtain
satisfactory aesthetic results employing non-operative tech-
niques. This is feasible inasmuch as the ear cartilage is mark-
edly elastic at birth and it gains resiliency only during the
early weeks of neonatal life. Therefore, it is possible to mod-
ify at birth the aesthetics of a malformed ear by utilizing
auricular devices.
Matsuo [28] showed how loop ears, Stahl’s ears, promi-
nent ears, and certain cases of cryptotia may be corrected by
simply shaping the tissues with the hands and then constrict-
ing them into a normal position by means of different types
of splints, made with silicone or spongy materials and fixed
with elastic bandage or adhesive tapes. Usually the useful
time to carry out such treatments lies between the early days
and the sixth week of neonatal life. The results are unsatis-
factory after such a period.
10 Pearls and Pitfalls
We would like to remind that preoperative planning, consist-
ing in a scrupulous evaluation of local anatomy, auricular
angles, and cartilage plasticity, is essential for an accurate
selection of the corrective technique to be used.
The retro-auricular skin incision should be carried out by
paying attention to the patient position on the operating
table. It would be better, therefore, to incise first the lower
portion and then the upper portion of the skin ellipse, in
order to prevent the blood from soaking the operative field.
The authors believe that the retro-auricular skin incision
should not be extensive, since a tense skin closure facilitates
cicatricial hypertrophy. Hemostasis should be most accurate
at each stage of the surgical procedure, as a hematoma often
leads a recurrence of the malformation or it may constitute
the substrate for an infection. The cartilage incision for
accessing the lateral surface should be carried out by press-
ing on the knife rather than by allowing it to slide as it
occurs when incising the skin; in such a way the accidental
incision of the skin of the lateral aspect of the ear pavilion,
and of the cartilage as well, is avoided. Once the cartilage
flap has been prepared, it is advisable to use uncolored
absorbable sutures to stabilize the new anthelix. The selec-
tion of absorbable material is related to the temporary
Otoplasty
immobilization, which is aimed at steadying the cartilage in
the new corrected position.
The hemostasis of deep soft tissues on the anterior auricu-
lar aspect should be done by means of a protected bipolar
forceps equipped with thin tips as to avoid thermal damage
that might be transmitted to the skin, thus generating a full
thickness defect that would expose the cartilage and conse-
quently facilitate an infection.
Once the surgical procedure is completed, the skin suture
should not be tightly shut; there is no need for a subcutane-
ous suture; it would be appropriate to proceed only with
single everting skin sutures, which allow for the draining of
a prospective hematoma.
The surgical dressing should be slightly compressive.
Such compression is obtained by using an abundant amount
of cotton wool and by avoiding application of the gauze
directly on the skin since it could produce decubitus ulcers.
Informed Consent
For a good outcome from the surgical procedure patient
information must be understandable, clear, and detailed.
Patient information facilitates both the establishment of a
relationship between the physician and patient based on
trust, and the correlation of patient’s expectations to the
actual surgery. In addition, it indicates the expected result of
the surgical procedure as well as the behavioral rules which
can be followed in order to facilitate a satisfactory outcome.
The patient should become acquainted with the problem. He
or she has to consider himself or herself not just a sculpture
to be shaped, but an active element of the remodeling and
healing process.
The informed consent form used by the authors is drawn
according to the guidelines issued by the Italian Society of
Reconstructive and Aesthetic Plastic Surgery and it is in part
modified on the basis of the authors’ clinical experience.
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Otoplasty: anterior scoring technique and results in 500 cases. Plast
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 Part VIII
The Face: Surgical Treatment
 History of Facial Rejuvenation
Riccardo F. Mazzola and Isabella C. Mazzola
1 Introduction
Humankind has always been concerned by death and old age,
something unavoidable in life. As we get old, we lose our vital-
ity, mental capacity, and beauty. It is no wonder that people seek
and try to invent items and solutions that stop aging or reverse
aging. The question is, exists somewhere the Fountain of Youth
(Fig. 1), a myth for anything that potentially increases longevity
and maintains beauty? Did anyone find it? The legend goes back
to at least fifth century B.C., when Greek historian Herodotus
wrote of such a fountain, which contains a special type of water
in the land of the Macrobians, which gives the Macrobians their
exceptional longevity. In the sixteenth century, the Spanish
explorer Juan Ponce de León (1474–1521) and his crew were
the first recorded Europeans to set in Florida. According to a
popular anecdote, Ponce de León discovered Florida while
searching for the Fountain of Youth, a magical water source
capable of reversing the aging process and curing sickness.
Regrettably, the fountain of youth does not exist, but
numerous solutions available through centuries may help
human beings to maintain or even improve facial rejuvena-
tion, the so-called antiaging techniques. In this chapter, we
will review their evolution.
Basically, facial rejuvenation can be obtained either with
cosmetic/medical treatments, or surgical methods, in other
terms noninvasive procedures like creams, ointments, mini-
mally invasive like chemical peeling, dermabrasion, fillers, or
invasive like surgery. The technology-dependent options such
as radiofrequency and laser, introduced in a relatively recent
period, are excluded from the present historical review.
R.F. Mazzola, MD (*)
Department of Clinical Sciences and Community Health,
Fondazione IRCCS Ca’ Granda, Ospedale
Maggiore Policlinico, Milan, Italy
e-mail: riccardo.mazzola@fastwebnet.it
I.C. Mazzola, MD
Klinik für Plastische und Ästhetische Chirurgie,
Klinikum Landkreis Erding, Erding, Germany
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_59
2 Use of Cosmetics: A Historical
Overview
Cosmetics are as old as vanity. Throughout the centuries
much has been written about use of cosmetic remedies alone
or in combination, beginning from ancient Egypt, where
facial wrinkles, a consequence of excessive exposure to the
sun and not just of old age, were managed by applying a
wax-based blend containing gum of frankincense, moringa
oil, ground Cyprus grass, and fermented plant juice. Removal
of upper layer of the skin for maintaining a youthful look
was by honey, red natron, and salt of the North pulverized
together. Face and limbs were rubbed with it [1].
In the Renaissance, the Italian physician Giovanni
Marinelli (sixteenth century) published the first textbook
entirely devoted to the beauty of women and how to preserve
it with creams, ointments, and other remedies [2]. For facial
wrinkles, he suggested the use of powder of deer’s horn
mixed with broad beans.
A few years later, Girolamo Mercuriale (1530–1606),
Professor of Practical Medicine at Padua University, wrote
De Decoratione, an account on cosmetics where he demon-
strated how it was possible to improve the appearance and
the beauty of the body [3]. On a completely opposite advice
was the English physician John Bulwer (1606–1656). While
appreciating the perfection of the woman face, he was strongly
against any sort of cosmetic remedy (Fig. 2) and modifica-
tion of the body, unless provided by nature, what he called
“the artificial changling” had to be condemned. His book
“Anthropometamorphosis…”, published in 1653, is replete by
numerous illustrations, which tries to demonstrate the foolish-
ness of the human mind for the excess of vanity [4].
3 Chemical Peels and Dermabrasion
Resurfacing and restoring skin with chemical peeling
was introduced in the second half of the nineteenth cen-
tury by the Austrian dermatologist Ferdinand Ritter von
841
842
Fig. 1 The fountain of youth (From: Colonna [39])
Hebra (1816–1880), founder of the Vienna School of
Dermatology. He used exfoliative agents, like phenol, cro-
ton oil, nitric acid in various cautious combination for treat-
ing freckles and skin irregularities. In 1882, the German
dermatologist Paul Gerson Unna (1850–1929) reported the
advantages of salicylic acid, resorcinol, phenol, and TCA
(trichloroacetic acid) [5]. Since then chemical peeling has
been largely employed, obtaining consistent results mainly
of sun-damaged skin alone or in conjunction with surgery.
Dermabrasion represents another option for skin resurfac-
ing. In 1905, the German dermatologist Ernst Kromayer
(1862–1933) invented an electrically powered instrument
that rotates a burr which could remove the superficial skin
layers at various depths [6]. Nowadays, with the advent of
laser resurfacing, interest for dermabrasion has been par-
tially eclipsed.
R.F. Mazzola and I.C. Mazzola
4 Fillers
The history of injectables, often disseminated by disastrous
and sometimes tragic results, is very instructive.
4.1 Paraffin
Paraffin wax, discovered in 1830 by Baron Carl von
Reichenbach (1788–1869), a notable German chemist and a
member of the prestigious Prussian Academy of Sciences,
was the first injectable material ever used in modern times.
J. Leonard Corning (1855–1923), a New York City neu-
rologist, the discoverer of spinal anesthesia and the Viennese
physician Robert Gersuny (1844–1924) began to experiment
with paraffin in the late nineteenth century apparently simul-
taneously and independently [7]. Leonard Corning used
paraffin to prevent reunion of nerves after subcutaneous neu-
rotomy and to enhance the antalgic effect of cocaine on some
nerves of the sensibility [8], whereas Gersuny to solve fea-
tural imperfections, urinary incontinence, velo-pharyngeal
incompetence, Romberg disease, etc [9].
But one of the most common indications was correction
of saddle nose deformity due to cartilage reabsorption, very
frequent problem for the diffusion of syphilis. Other applica-
tions were deep nasolabial folds, frown lines, neck wrinkles,
etc. With a melting point between 46 and 68 °C (115 and
154 °F), paraffin could be introduced without incisions either
alone or, at different times, according to Gersuny, in combi-
nation with Vaseline, or Vaseline alone, or Vaseline with
olive oil. Apparently, the material resulted inert.
The armamentarium was easy obtainable: the paraffin in
pearls or in cubes, a pot for melting the wax (Fig. 3), and a
syringe (Fig. 4) [7, 10].
With the diffusion of the procedure and the immediate
favorable results obtained, an order of charlatans climbed on
the paraffin success. They began to advertise in newspapers,
yellow pages, and to give demonstrations in beauty salons
and drugstores. Paraffin represented the panacea for a variety
of cosmetic and functional applications without the need for
the surgical knife. News of this apparently ideal substance
began to spread through the medical community. The demand
for removing the typical characteristic of saddle nose defor-
mity was great and the immediate outcome particularly
favorable (Fig. 5).
Complications appeared soon. The new miracle began to
fade. Formation of granulomas by foreign body reaction,
specifically named “paraffinomas”, due to wax, oil and
Vaseline penetrated within the tissues was the most com-
mon event almost impossible to solve, but also causing pul-
monary embolism, infections, etc. Removing paraffin
proved to be more difficult than injecting it (Fig. 6). Kolle
in his book on cosmetic surgery, published in 1911 [10],
History of Facial Rejuvenation 843

Fig. 2 Allegorical representation of Nature (center) rejecting human beings (right), who underwent “artificial changling” or modification of the
body, “de abusu partium” (the abuse of parts) (From Bulwer [4])

Fig. 3 Paraffin heater (From Kolle [9])

Fig. 5 Paraffin advertisement, ca. 1902 (From Stein [7])

reported a series of side effects ranging from inflammatory

reactions to tissue necrosis and embolism. Despite this,
paraffin continued to be injected mainly into the nose, face,
and breast until the 1960s. Robert Goldwyn, in his paper on
Fig. 4 Syringe for paraffin injection (From Kolle [9]) paraffin story [11], described the drama of one celebrated
844
Fig. 6 Dramatic complication following paraffin injection. Diffuse
facial paraffinomas with attempted removal (From: Loeb [40])
victim of the paraffin, the Duchess of Marlborough, who, in
1935, had paraffin and wax introduced into her face and
forehead, causing an incredible number of bumps and
swellings. She was completely disfigured, becoming a
recluse for the rest of her life and saw only close friends,
despite she was considered one of the most beautiful
women of the planet, before the event occurred. She died in
1977 completely forgotten.
4.2 Other Fillers
Charles C. Miller (1880–1950) from Chicago, one of the
first cosmetic surgeons, published in 1926 Cannula implants,
a textbook on fillers to modify featural imperfections [12].
He proposed the use of gutta-percha, celluloid or rubber
sponges grounded in a mill (Fig. 7) and heated before inject-
ing them to correct depressions, crow’s feet, nasolabial
grooves, and saddle noses. He asserted that these stuffs were
inert, well tolerated and particularly effective. He used a
special syringe with barrel to introduce the material
subcutaneously.
R.F. Mazzola and I.C. Mazzola
Fig. 7 Rubber and gutta-percha grounded in a mill before their inser-
tion into the face (From Miller [12])
4.3 Liquid Silicone
James Franklin Hyde (1903–1999), an American chemist is
credited with the launch of the silicone industry in the 1930s.
For this he was called the “Father of Silicones”. His work led
to the formation in 1943 of Dow Corning Corporation cre-
ated to pioneer the development of silicone products as a
result from the alliance between the Corning Glass Works
and the Dow Chemical.
Because of their low toxicity, pure silicones presented a
small risk of unfavorable biological reactions and had
obtained widespread recognition and popularity among the
medical circles.
In the 1960s, a new miraculous filler appeared on the mar-
ket: the liquid silicone, an amazing chemical product – man-
ufacturers advertised – that could turn old faces into young,
erase wrinkles, and change hypoplastic breasts into a C cup,
without the minimal problem. Its story curiously recalls the
paraffin affair.
While augmentation surgery for breasts using foams or
other materials evolved significantly between the 1950s
and the 1960s, the unofficial practice of silicone injections
gained popularity [13]. Considered an inert material that
could be easily sterilized, the liquid was injected directly
into women’s breasts, or into the face for augmenting lips
or improving nasolabial folds. The “procedure” spread out
so rapidly that silicone available for implantation was dif-
ficult to find.
History of Facial Rejuvenation 845

However, after an initial honeymoon period, dramatic a

complications such as discoloration, infections, migration,
granulomas formation, the so-called siliconomas, hardening
of tissues, were soon being documented.
Liquid silicone has been used for soft tissue increase for
over 30 years. There is an extensive literature on facial treat-
ments, particularly lips, frown lines, crow’s feet, cheeks, etc.
Due to the adverse side effects, injection of liquid silicone
for cosmetic purposes ceased in January 1992, when the US
Food and Drug Administration (FDA) declared a morato-
rium on the use of this device.

4.4 Fillers Nowadays

b
In recent years, demand for rejuvenation using fillers has
dramatically increased. Patients are seeking more and more
quick recovery and minimally invasive nonsurgical proce-
dures. This is the reason why filler selection has considerably
expanded ranging from collagen to poly-l-lactic acid,
hydroxylapatite, hyaluronic acid (HA), among others.
Fillers in aesthetic facial improvement represent one of
the most popular minimally invasive cosmetic procedures
[14]. A huge business is behind them. Nowadays, fillers can
achieve spectacular results, but may give rise to numerous
dramatic complications (e.g., formacryl). Their story is fasci-
nating and at the same time instructive.
The lesson drawn from their use, often uncontrolled,
indicates that physicians must always carefully develop a Fig. 8 (a) Pre- and (b) postoperative case of facial atrophy improved
clinical performance measure, before injecting products by fat injection (From Holländer [15])
not sufficiently tested or whose side effects are not clearly
documented.
5 Surgery for Facial Rejuvenation

4.5 Fat 5.1 Face-Lifting

To contrast paraffin complications, fat injection was pro-
posed in 1910 by the German surgeon Eugene Holländer
(1867–1932) as a more natural filler [15] and in 1926, by
Charles C. Miller from Chicago [12]. In particular,
Holländer injected fat into the face to minimize the conse-
quences of facial atrophy (Fig. 8). In the beginning, sur-
geons enthusiastically favored the technique of fat grafting.
But in the 1930s, with growing experience, clinicians real-
ized that the very encouraging early results, worsened at
long term due to unpredictable reabsorption rate, tendency
to form cysts and become fibrotic. This is the reason why
use of fat transplantation was considered questionable and
fell from favor. In the early 1980s, with the advent of lipo-
suction, fat grafting was rediscovered and in the 1990s,
Sydney Coleman systematized the technique, which now
ranks among the most popular procedures and it is regarded
as one of great clinical value [16].
The German Eugen Holländer is credited for being the first
one to report on a face-lifting. “Victim myself of the art of
feminine persuasion, a few years ago, I performed the exci-
sion of a piece of skin along the hairline and the natural
folds of the ageing wrinkles and I rejuvenated the drooping
cheek for the satisfaction of the beholder” [17]. In a later
publication, he states that this occurred in 1901 and that the
patient was a Polish aristocrat.
At the beginning of the century, Charles C. Miller, con-
sidered by some the “father of modern cosmetic surgery”,
and by others “an unabashed quack”, published in 1907
Cosmetic Surgery. The Correction of Featural Imperfections,
the first textbook on Aesthetic Surgery, deals with proce-
dures for the facial rejuvenation. In the second edition,
issued 17 years later [19], he made considerable improve-
ments, dedicating an entire chapter to the different face-
lifting operations, like forehead, temple, cheek (as he named
846 R.F. Mazzola and I.C. Mazzola

it) (Figs. 9 and 10). The chapter contains numerous illustra-
tions of different face-lifting procedures, many of them
completely unrealistic. No pre- and postoperative photo of
patients is supplied.
Interestingly, Frederick S. Kolle (1872–1929) from New York
in his texbook Plastic and Cosmetic Surgery, the second one on
aesthetic surgery in terms of priority, issued in 1911, does not
mention any operation for facial rejuvenation [10].
After the dramatic years of the First World War, the inter-
war period was an exciting moment to live. The Great War
was just a memory and the world seemed to finally enjoy
peace, calm and face a better future.

a b

Fig. 9 (a) Pre- and (b) postoperative illustration of a browlift (From Miller [19])

a b

Fig. 10 (a) Pre- and (b) postoperative illustration of a face-lifting (From Miller [19])
History of Facial Rejuvenation 847

Many surgeons, fully trained in facial reconstruction, tal-naso-labial rhytidectomy” (Fig. 11), whereas for the redun-
enthusiastically started to take care of the surgery of the wel- dant skin at the angle of the mandible he removed a large ellipse
fare, in other terms cosmetic procedures. in the temporal region. Finally, for the gobbler neck he performed
In the USA, Lyons H. Hunt (1882–1954), Henry J. a “cervico-rhytidectomy”, with an incision not dissimilar from
Schireson (1881–1949), J. Howard Crum (1888–1975), today’s standard procedure (Figs. 12 and 13).
Maxwell Maltz (1899–1975), J. Eastman Sheehan (1885–
1951), Jacques W. Maliniak (1889–1976) and Vilray P. Blair
(1871–1955) represented the full range of practicing plastic
surgeons with a particular interest for facial rejuvenation [13,
20]. All played important roles in shaping professional and
public image of our specialty.
Lyons H. Hunt of New York, born in London, published in
1926 Plastic Surgery of the Head, Face and Neck [21], accurately
written and illustrated, with wide range of subjects covered, with
an important section on cosmetic surgery for facial rejuvenation.
Hunt used a variety of face-lifting techniques depending on the
specific area to be treated. For the cheeks he carried out the “fron-

Fig. 12 The technique of facial cervicofacial lifting (Illustrated by

Fig. 11 The technique of facial rhytidectomy (Illustrated by Hunt [21]) Hunt [21])

a b

Fig. 13 (a) Pre- and (b) postoperative illustration of a cervical rhytidectomy (From Hunt [21])
848 R.F. Mazzola and I.C. Mazzola

On a complete different wavelength was The Making of a Suzanne Nöel (1878–1954), active feminist and founder
Beautiful Face or Face Lifting Unveiled [22] by J.W Crum, a of the Soroptimist Club of Europe, operated in the very
very commercial textbook, one of the firsts of this genre. No exclusive 16th arrondissement where she organized an active
technical description of any surgical procedure was supplied, solo practice. She specialized herself in techniques for facial
apart from saying that the procedure lasts between 40 and rejuvenation like blepharoplasty and face-lifting. To design
60 min. No pre- and postoperative photo was shown. Crum her skin resections in the forehead, temple, pre- and retroau-
defined face-lifting as the “most effective facial operation ricular regions she used a variety of elliptical templates
whereby loose, flabby skin is made to disappear from the (Fig. 15a, b). Her operations were simple, but effective,
face and neck as if by magic”. He performed the first face- strictly performed on an outpatient basis (Fig. 16). For this
lifting on record in the grand ballroom of the Pennsylvania reason undermining was minimal. Many of her patients under-
Hotel in New York in 1931, in front of more than 600 women, went several staged procedures. After surgery, ladies could
during which a pianist accompanied him with appropriate comb their hairs, drink a cup of tea, and go home (Fig. 17).
popular tunes, flashbulbs popped and men and women
fainted. He practiced in New York from 1928 until his death.
HJ Schireson, from Chicago, had a moment of fame for
having successfully “lifted” the face of an English actress
famous for her title as well as for her professional
achievements. He then promised to correct the bowlegs of a
showgirl through an operation. Regrettably, something went
wrong and both legs were amputated above the knee.
Schireson had his license revoked. Despite this, he continued
to operate, visit patients, and advertise in beauty magazines.
In 1938, he published As Others See You: The Story of Plastic
Surgery, a book which was well received and positively
reviewed by the press [23]. In 1944, Time dubbed him the
king of quacks [13]. A few years later, he issued a well-illus-
trated and cogent pamphlet Your new face is your fortune;
what plastic surgery can do for you, in which he tried to
demonstrate the importance of facial appearance for estab-
lishing a favorable first impression.
Jacques W. Maliniak, founder of the American Society of Fig. 14 Face-lifting with extensive skin undermining and an oblique-
Plastic Surgeons in 1931, was the Author of Sculpture in the vector loop to suspend tissues (From Maliniak [24])
Living, published in 1934 [24]. Despite the commercial set-
ting, the contents included technical details of the procedures a b
shown, to improve breast, nose, and face. Numerous pre- and
postoperative photos were supplied along with schemes of
the face-lifting operations. He stated that “a successful and
lasting face-lifting requires extensive excision and wide
undermining of the skin of the face (Fig. 14). The fine scars
were concealed in the hair line and behind the ears”. He con-
tinued by saying that “the inadequate ‘simplified’ method
used by ‘beauty specialist’ in which small elliptical excisions
are made in the hairline, results in a slight stretching of the
skin, which at best lasts only a few months.”
Maxwell Maltz, excellent surgeon, was a master of pub-
licity and a prolific writer. Apart from four autobiographical
works, the first of which dated 1936, Maltz published at least
ten books between 1960 and 1975, on cosmetic surgery.
On the other side of the Ocean, aesthetic surgery devel-
oped mainly in Paris, Berlin, and Vienna.
In Paris worked Suzanne Nöel, Raymond Passot, Julien
Bourguet, and Maurice Virenque. In Berlin Jacques Joseph. Fig. 15 The templates and the ruler used by Suzanne Nöel to design
In Munich, Erich Lexer. In Vienna, Ernst Eitner. her skin resection for face-lifting (From Nöel [25])
History of Facial Rejuvenation 849

Fig. 16 (a) Pre- and (b) postoperative illustration of a face-lifting performed by Suzanne Nöel (From Nöel [25])

a b

Fig. 17 After surgery, patients could comb their hairs (a) or drink a cup of tea (b) before going home (From Nöel [25])
850 R.F. Mazzola and I.C. Mazzola

In 1926, Suzanne Nöel published La Chirurgie Esthétique:

Son Rôle Sociale [25], one of the first textbooks on this topic
and the first written by a woman. In 1928, she was awarded
the Legion of Honour.
Julien Bourguet (1876–1952), renowned for having first
described the transconjunctival approach for baggy eyelid in
1929 [26], wrote La véritable Chirurgie Esthétique du Visage
in 1936 [27] where he showed spectacular results of surgery
for facial rejuvenation (Fig. 18).
Raymond Passot (1886–1933) added innovative tech-
niques for breast ptosis, abdomen, facial rejuvenation, and
eyelid correction using Bourguet’s method. His book La
Chirurgie Esthétique pure, dating from 1931 [28], shows a
wide range of operations in the field of aesthetic surgery
(Figs. 19 and 20).
Maurice Virenque (1888–1946) was a maxillofacial sur-
geon from Paris and a member of the French association
“Les gueles cassées” (the facial cripples). He worked in Le
Mans military hospital and for a certain period of time he
was Tessier’s chief, when Paul Tessier attended the Le
Mans, Maxillo-Facial Unit. He was aware of the impor-
tance of aesthetic surgery. Due to his large experience in
maxillo-facial surgery and his great knowledge of facial
anatomy, Virenque developed new original approaches to

Fig. 19 Title page of Passot’s publication (1931) [27]

Fig. 18 Title page of Bourguet’s publication (1936) [26] Fig. 20 Illustration of Passot’s incision for face-lifting (1931) [27]
History of Facial Rejuvenation 851

the correction of the aging face. In an era where face-lifting
was purely by skin undermining, he advocated the plication
of the deep aponeurotic layers of the face, the use of sus-
pension threads, and the vertical vector (Fig. 21), technique
which has recently been rediscovered by P. Tonnard and
A. Verpaele, and renamed MACS lift by them [29]. His
1927 publication Traitement Chirurgical des Rides de la
Face et du Cou (Surgical Management of the Wrinkles of
the Face and Neck) [30] is of great importance in the his-
tory of face-lifting. Regrettably, it is seldom acknowledged
and quoted.
In Berlin, Jacques Joseph (1864–1934), the father of aes-
thetic rhinoplasty, was well known for his operations for
facial rejuvenation and eyelid correction The design of skin
excision for face-lifting, illustrated in Joseph’s book, became
soon the standard method [31] (Fig. 22).
Similar incisions were described by Erich Lexer (1867–
1937) in 1931 (Fig. 23), at that time Professor of Surgery at
University of Munich [32], and by Ernst Eitner (1867–1955)
from Vienna [33].
Gustav Aufricht was among the first ones to describe
the plication of the deep structures [34]. In the 1970s,
Tord Skoog [35] realized that skin and subcutaneous tis-
sue are closely related to each other to form a compound
unit which includes the superficial fascia. By pulling on
the orbicularis and platysma muscles, wrinkles are greatly
reduced and the final result lasts longer. The importance
of the fascia superficialis was first emphasized by the

a b

c d

Fig. 21 Virenque’s innovative face-lifting procedure. (a) pre-capillary and pre-auricular incision ending at the lobule; (b) the three suspension
loops; (c) the skin excision with vertical vector; (d) final result (From Virenque [30])
852
Fig. 22 Joseph face-lifting incisions (From Joseph [31])
Fig. 23 Lexer face-lifting incisions (From Lexer [32])
Italian Giuseppe Sterzi (1879–1919) who described it in
detail in 1910 [36]. Regrettably, the paper, written in
Italian, was seldom quoted. It was Paul Tessier who under-
stood the importance of this structure and gave to Mitz
and Peyronie the task of performing the anatomical study.
The results of their research were published in 1976 and
the fascia named SMAS (Superficial Musculo-Aponeurotic
System) by them [37].
This opened a new era in management of face-lifting.
R.F. Mazzola and I.C. Mazzola
Our overview of the evolution of ideas in facial rejuve-
nation ends here. A great variety of face-liftings are avail-
able nowadays. But their description escapes from our
goal.
Conclusions
Face-lifting started in the 1920s with simple, mini-inva-
sive procedures performed under local anesthesia and on
outpatient basis. In recent years, it has considerably
evolved, from pure skin dissection, with a limited durabil-
ity over the years, to more and more aggressive tech-
niques, which involve the deep structures. Knowledge of
anatomy and physiology of the aging process was at the
basis of this development.
References
1. Wreszinski W (ed) (1912) Der Londoner Medizinische Papyrus
und der Papyrus Hearst, vol 153. Hinrichs, Leipzig
2. Marinelli G (1562) Gli Ornamenti delle donne. de’ Franceschi,
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3. Mercuriale G (1585) De Decoratione. P. Meietto, Venezia
4. Bulwer J (1653) Anthropometamorphosis: man’s transform’d: or
the artificial changeling. W. Hunt, London
5. Brody HJ, Monheit GD, Resnik SS et al (2000) A history of chemi-
cal peeling. Dermatol Surg 26:405–409
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Verfahren in der dermtologischen Kleinchirurgie. Chir Dermatol
Ztschr 12:26–36
7. Stein AE (1904) Paraffin-Injektionen. Theorie und Praxis. Enke,
Stuttgart
8. Corning IJ (1896) The use of congealed oils to prevent reunion of
nerves after their subcutaneous division: a contribution to the radi-
cal treatment of certain forms of neuralgia. Med Rec NY
50:809–814
9. Gersuny R (1900) Über eine subkutane Prothese. Ztschr Heilk
21:199–204
10. Kolle FS (1911) Plastic and cosmetic surgery. D. Appleton,
New York, p 209
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11. Goldwyn RM (1980) The paraffin story. Plast Reconstr Surg
65:517–524
12. Miller CC (1926) Cannula implants and review of implantation
techniques in esthetic surgery. Oak Press, Chicago, pp 66–71
13. Haiken E (1997) Venus Envy. A history of cosmetic surgery. The
Johns Hopkins University Press, Baltimore
14. Born TM, Airan LE, McGrath MH et al (2009) Soft tissue fillers in
aesthetic facial surgery. In: Nahai F (ed) The art of aesthetic sur-
gery. Quality Medical Publishing, St. Louis, pp 223–288
15. Holländer E (1910) Über einen Fall von fortschreitenden Schwund
des Fettgewebes und seinen kosmetischen Ersatz durch
Menschenfett. Munch Med Wochenschr 57:1794–1795
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regeneration. Quality Medical Publishing, St. Louis
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Handbuch der Kosmetik. von Veit, Leipzig, p 688
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imperfections. Oak Printing, Chicago
19. Miller CC (1924) Cosmetic surgery. The correction of featural
imperfections, 2nd edn. FA Davis, Philadelphia, pp 57–95
20. Zacher JB (1983) Platic surgery in the late 1920s. Three points of
view. Clin Plast Surg 10:665–667
21. Hunt HL (1926) Plastic surgery of the head, face and neck. Lea &
Febiger, Philadelphia, pp 263–267; 368–372
22. Crum JH (1928) The making of a beautiful face; or, face lifting
unveiled. Walton, New York
23. Schireson HJ (1938) As others see you. The story of plastic surgery.
Macaulay, New York
24. Maliniak JW (1934) Sculpture in the living. R. Pearson, New York,
pp 140–160
25. Nöel S (1926) La Chirurgie Esthétique. Son rôle sociale. Masson, Paris
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les yeux sans cicatrice. Arch Franco Belges Chir 31:133–136
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Plon, Paris, pp 128–148
28. Passot R (1931) La Chirurgie Esthétique pure. Technique et
Résultats. Doin, Paris, pp 155–184
29. Tonnard PL, Verpaele AM (2007) Short-scar face lift. Operative
strategies and techniques. Quality Medical Publishing, St. Louis
30. Virenque M (1927) Traitement Chirurgical des Rides de la Face et
du Cou. In: Pauchet V (ed) La Pratique Chirurgicale Illustrée, vol 7.
Doin, Paris
31. Joseph J (1931) Nasenplastik und sonstige Gesichtsplastik nebst
einem Anhang über Mammaplastik. Kabitzsch, Leipzig
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A. Barth, Leipzig, pp 548–553
33. Eitner E (1932) Kosmetische Operationen. Ein kurzer Leitfaden für
den Praktiker. J. Sprimger, Wien, pp 67–71
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tic surgeons. E&S Livingstone, Edinburgh/London, pp 495–502
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anatomiche. Firenze, Nicolai
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(SMAS) in the parotid and cheek area. Plast Reconstr Surg 58:80–88
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I, Chap. 11. Bindoni, Venezia
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40. Loeb HW (1914) Operative surgery of the nose, throat and ear.
Mosby, St. Louis, p 350
 The Aging Face
Bryan C. Mendelson and Justin X. O’Brien
Tempus fugit. Time flees.
Half a millennium has passed since Leonardo da Vinci com-
posed this frank, yet detailed self-portrait in which he described
the effects of time on his face. Our preoccupation with facial
aging has a long and well-deserved history. It is difficult to
envisage da Vinci’s portrait devoid of the extensive grooves
and furrows, such is their contribution to our perception of
what the artist is showing us. A brief glimpse of a person’s face
affords a wealth of information, including an estimate of the
person’s age, gender, emotional state, racial background, and
energy levels. We use these cues, almost subliminally, to guide
our interactions with people, as the cues are predictive of the
behaviour we should expect from each person in return.
Unfortunately, some age-related changes of the face can
incorrectly convey a person’s emotions, level of interest, and
even their overall health. When correcting these changes to
restore a more youthful appearance, the aesthetic plastic sur-
geon must understand and respect the anatomical changes
occurring in the aging face, so that the facial expression is
not unintentionally altered.
Aging of the face is a complex and still incompletely
understood process. While the visual effect is obvious, the
process is not easily described, as it is the culmination of the
simultaneous changes of several different, but adjacent tis-
sues as well as their interaction.
The purpose of this chapter is to introduce a systematic
approach to analysing aging of the face. Accordingly, this
chapter is structured around a description of the concentric
layered structure of the face and its regional variations. Then
the effect of aging on the structure of each layer is analysed,
so that each of the characteristic stigmata of aging can be
correlated with its anatomical origin.
B.C. Mendelson, FRCSE, FRACS, FACS (*)
The Centre for Facial Plastic Surgery,
Melbourne, VIC, Australia
e-mail: drbryan@bmendelson.com.au
J.X. O’Brien, MD
Taylor Laboratory, Department of Anatomy and Neuroscience,
University of Melbourne, Melbourne, VIC, Australia
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_60
1 Tissue Layers of the Face
The scalp is the basic archetype for understanding facial
anatomy, as it contains the same tissue layers and planes,
without the complexity of the modified areas of function
found overlying the bony cavities of the face proper [1].
The skin provides the visible surface that undergoes
intrinsic changes as well as reflecting changes to the deeper
soft tissue layers of the face. Even in this first tissue layer,
specialisations occur, with thick dermis containing addi-
tional collagen over the less mobile areas, such as the nasal
tip, and thin dermis over mobile anatomical areas, the thin-
nest being on the eyelids (Fig. 1) [1].
The subcutaneous layer of the scalp and face is the second
layer and is formed by the subcutaneous fat and the retinacular
cutis that connects the dermis with the underlying galea apo-
neurotica and superficial musculoaponeurotic system (SMAS),
respectively. In the scalp, the second layer has a uniform thick-
ness and consistency of fixation to the overlying dermis, while
in the face proper, there is considerable variation [1].
The arrangement of the retinacular cutis fibres of the face
is not homogenous. It varies in accordance with the anatomy
of the fourth layer (discussed later). Where retaining liga-
ments are located in the fourth layer, the corresponding reti-
nacular fibres cross the subcutaneous tissue layer in a
perpendicular fashion to reach the dermis and retain the der-
mis here in close proximity to the underlying ligaments.
Where soft tissue spaces are located in the fourth layer,
the overlying retinacular fibres are oriented more parallel to
the dermis, providing less restriction to movement [1].
The third layer of the archetype corresponds to the con-
fluence of the galea aponeurotica which invests the occipito-
frontalis in the scalp, the temporoparietal fascia of the
temporal region, the superficial musculoaponeurotic system
(SMAS) of the face, and the superficial cervical fascia of the
neck. The superficial cervical fascia invests platysma in the
same manner as the galea aponeurotica invests the occipito-
frontalis in the scalp and the SMAS invests orbicularis oculi
and platysma in the face. The fascia is thick on the deep sur-
855
856
Fig. 1 Fascial layers of the scalp and face. 1 Skin. 2 Subcutaneous tis-
sue. 3 SMAS. 4 Areolar tissue. 5 Periosteum. The commonly utilised
surgical planes are shown in relation to the tissue layers
face of these superficial muscles, and thin on the superficial
surface, extending into the retinacular cutis. This allows the
superficial muscles to act on the skin. Where the superficial
flat muscles of the face are not present, these two fascial lay-
ers are fused and become aponeurotic.
The arrangement of the aponeurosis into three laminae [2]
could be sub-classified as: 3a – the thin fascia on the outer
surface of the muscle, 3b – the layer of superficial flat mus-
cle, and 3c – the thicker fascia on the underside of the mus-
cle. Where muscle is not present, the fasciae 3a and 3c fuse.
Additionally, in certain areas of the face, a small fat pad is
interposed between the muscle and its underlying fascia, as
in the galea fat pad beneath the frontalis over the superior
orbital rim medially and the ROOF (retro-orbicularis oculi
fat) over the superolateral orbital rim [3].
B.C. Mendelson and J.X. O’Brien
In the scalp, the fourth layer is a glide plane composed of
loose areolar tissue that allows the overlying layers to move
relative to the skeleton. In the face, consistent with the com-
plexity of its function, the fourth layer is more complex, as it
contains more discrete areas of glide plane, known as the soft
tissue spaces. These spaces are separated by the immobile
retaining ligaments and immobile areas of fascial condensa-
tion that contain important anatomical structures, in addition
to the deep layer of mimetic muscles extending from their
periosteal origin [4].
With regard to facial aging, there are several clinically
important spaces within the fourth layer; the preseptal
space of the lower lid, the prezygomatic space, and the
premasseter space. Each of these spaces has a floor formed
by tissue of the fifth layer, and a roof formed by tissue of
the third layer. Each space has boundary structures that
have a varying propensity for the development of laxity
with aging. These spaces will be discussed with respect to
age-related changes visible on the regions of the face that
they underlie.
The fifth tissue layer is the deep fascia and periosteum.
The periosteum of the skull and facial bones is confluent
with the ‘masticator’ fascia and with the investing layer of
the deep cervical fascia of the neck. In the neck, this layer of
fascia invests sternomastoid and trapezius, while in the face,
the muscles of mastication are invested; temporalis, masse-
ter, and the lateral and medial pterygoids. The masticator
fascia over temporalis is known as the ‘temporalis fascia’,
and over masseter as the ‘masseter fascia’.
The investing layer of deep cervical fascia affords pro-
tection to the cervical plexus (deep) and the spinal acces-
sory nerve (within the fascial investiture) as they course
towards their destinations. Similarly, the masseteric fascia
affords protection to the zygomatic, buccal, and marginal
mandibular branches of the facial nerve as they course
anteriorly, changing plane only when they approach the
retaining ligaments of the fourth layer. It is this protection
of the facial nerve rami in the lateral face where they lie
deep to layer five that provides for safe dissection in the
fourth layer spaces.
2 Facial Aging
The signs of facial aging are derived from anatomical
changes across the various tissue layers. Among the first
noticeable changes are the expression lines and wrinkles
which begin as creases related directly to the contraction of
underlying muscles. With more advanced aging, additional
signs develop, not due to local contraction of an individual
muscle, but rather due to more diffuse movement of a tissue
mass, combined with the tethering effects of the retaining
ligaments.
The Aging Face
Fig. 2 Periorbital wrinkles. 1 Oblique and vertical glabellar lines. 2
Transverse glabellar lines. 3 Zygomatic smile lines. 4 Crow’s feet lines.
Lateral brow ptosis is also depicted
2.1 Expression Lines and Wrinkles
Expression lines and wrinkles represent relatively superficial
(in terms of anatomical plane) age-related change to the face.
Expression lines are produced by contraction of the mimetic
muscles and the consequent creasing of the overlying subcu-
taneous tissue and dermis (layers two and one). In youth,
expression lines are perpendicular to the direction of under-
lying muscle contraction and are present only temporarily,
during dynamic movement. However, years of repetition of
such muscular contraction along with changes in the elastic
quality of the skin and subcutaneous tissue leads to a perma-
nence of the expression lines as they become ‘etched’ in lay-
ers one and two and remain visible in repose.
The most conspicuous expression lines that contrib-
ute to the aged appearance of the face are glabella frown
lines, crow’s feet lines, zygomatic smile lines, and perioral
wrinkles.
Glabella frown lines are the result of repeated movement
of the mimetic muscles in the glabella region. Each is fixed
where it inserts in the dermis (first layer) under the medial
end of the eyebrow. The mimetic muscles producing these
lines are the medial head of the orbital portion of orbicu-
laris oculi, depressor supercilii, and the corrugator supercilii
(Fig. 2) [5].
Glabella frown lines are of three types. Vertical glabellar
lines are produced by the transverse head of corrugator super-
cilii, while the oblique glabellar skin lines may be caused by
the oblique head of corrugator supercilii or one, or all, of the
three medial eyebrow depressor muscles. Transverse glabella
lines are the result of action by procerus [5].
Crow’s feet lines are orientated perpendicular to fibres of
the underlying orbicularis oculi. As a result, the lines radiate
out from the lateral canthal region like the spokes of a wheel.
857
Repetitive action of the vertical orbicularis oculi fibres in the
region of the lateral orbicularis raphe contribute to the for-
mation of crow’s feet lines at their most lateral extent [6].
Consequently, the lines have a more horizontal orientation as
they extend laterally (Fig. 2).
Zygomatic smile lines are immediately inferior to the
more horizontally orientated crow’s feet lines. They are ori-
entated perpendicularly to orbicularis oculi muscle fibres
over the lateral extent of the prezygomatic space [1], and are
associated with elevation of the ‘cheek’ tissues that results
from a temporary skin excess due to the simultaneous con-
traction of zygomaticus major (Fig. 2).
Perioral wrinkles arise perpendicular to the purse string-
like contraction of the underlying orbicularis oris in the same
manner as the crow’s feet lines are related to the other major
sphincter in the face, orbicularis oculi. In contrast with the
expression lines at the corner of the eyes, those around the
mouth are located along the upper and lower edges as the
soft tissues of the lip lack the stiffness of the lids provided by
the tarsal plates, and do not have the lateral stability provided
by the medial and lateral canthal tendons.
In general, specific correction of dynamic wrinkles is
done by use of a neurotoxin on the muscle, whereas static
lines require a tightening of the laxity of the soft tissues. The
latter is usually sufficient to also camouflage the excess
effect of dynamic muscle contraction.
Expression lines develop perpendicular to underlying
superficial muscle contraction.
In youth, the expression lines are only seen during muscu-
lar contraction (dynamic expression lines). With aging, the
expression lines persist as wrinkles during muscular relax-
ation (static expression lines).
An increase in the amount of soft tissue laxity in an area
results in a greater amplitude of soft tissue movement on
muscle contraction, which explains the increased promi-
nence of expression lines and wrinkles with aging.
2.2 Ptosis and Tethering
Other changes of facial aging are historically more recalcitrant
to surgical rejuvenation, as they result from changes in the
third and fourth layers of the face. The outer three layers of the
face behave as a composite unit that moves over the spaces of
the fourth layer. In the long term, this composite unit under-
goes ptosis over the spaces, leading to an alteration of the posi-
tion of the soft tissue mass relative to the facial skeleton.
Because they insert directly into the dermis, the retaining
ligaments and deep mimetic muscles produce a tethering effect
at the boundaries of the spaces of the fourth layer. This tether-
ing effect is faithfully transmitted to the surface of the face as
skin furrows and grooves. Ptosis and tethering accentuate one
another at the borders of the spaces. Ptosis of less supported
858
Fig. 3 Boundaries of the frontal and upper temporal compartments:
Superior temporal septum (STS), temporal ligamentous adhesion (TLA),
supraorbital ligamentous adhesion (SLA). Other structures shown: infe-
rior temporal septum (ITS), periorbital septum (PS), lateral brow thick-
ening (LBT), lateral orbital thickening (LOT)
tissue overlying the spaces results in fullness, seen as increas-
ingly prominent folds. The changes in the underlying anatomy
explain why the folds and furrows occur pari passu.
Ptosis and tethering in the scalp is seen as temporal hood-
ing (lateral brow ptosis) and should be considered in refer-
ence to the anatomy of the frontal compartment and the brow.
The floor of the frontal compartment is the periosteum
overlying the frontal bone. The periosteum continues inferi-
orly over the superior orbital rim and into the orbit and is
confluent with the temporalis fascia laterally (layer 5) [1, 3, 4,
7–18]. The roof of the compartment (layer 3) contains the
paired frontalis muscles enclosed within their investing layer
of fascia [3, 6, 19] (the galea aponeurotica) which is confluent
with the temporoparietal fascia laterally [1, 3, 4, 6–13, 20–
38]. The ligamentous boundaries are summarised in Fig. 3.
The brow is at the inferior boundary of the frontal com-
partment that incorporates the ligamentous attachment of the
frontalis as the supraorbital ligamentous adhesion (SLA).
Inferior to the SLA are the retro-orbicularis oculi fat (ROOF,
subgaleal fat pad) containing the glabella muscles, and the
periorbital septum containing the lateral brow thickening.
B.C. Mendelson and J.X. O’Brien
Fig. 4 Dynamics of lateral brow ptosis. The active muscular forces are
indicated by dark arrows. The effect of gravity on the soft tissue of the
temporal region is indicated by the light arrow
The ROOF underlies the lower frontalis over the superior
orbital rim. The periorbital septum on the superior orbital
rim provides an indirect bony attachment for both the fronta-
lis and the orbicularis oculi muscles and plays a role in
restraining the brow and upper eyelid soft tissues [20]. This
firm attachment extends only over the medial two thirds of
the orbit and corresponds to the supraorbital ridge. Laterally,
less-dense connections exist that may be nearly as strong in
the younger, but become attenuated in the elderly [6, 20].
Temporal hooding results from attenuation of the retain-
ing structures in the lateral brow (part of the inferior bound-
ary of the frontal compartment) that allows the ROOF to
descend and bulge into the lateral part of the upper lid.
Gravitational descent is relatively unopposed over the tem-
ple, as there is a lack of dynamic muscular restraint to ptosis
lateral to the superior temporal septum and temporal liga-
mentous adhesion, compared to the restraint provided over
the frontal compartment by the frontalis muscle [3, 6].
Additionally, the vertically orientated fibres of the orbicu-
laris over the lateral orbital rim have a ‘depressor’ action on
the brow soft tissues (Fig. 4).
The composite structure (layers one, two, and three) over
the temporal region has less integrity than it does over the
forehead. The skin is thin and is not strongly fixed to the
underlying temporoparietal fascia by the retinacular cutis as
is the skin over the scalp and also of the midcheek (fixed by
the zygomatic ligaments) and the lower face (mandibular
ligament). This may explain why there is more superficial
The Aging Face 859

Fig. 6 The effect of loss of maxillary projection over a decade of aging

on the position of the soft tissues over the upper midcheek

Fig. 5 The midcheek. Structurally, the midcheek is formed by the con-

vergence of three adjacent but separate anatomical components: the lid-
cheek segment, the malar segment, and the nasolabial segment. When
the segments appear with aging, they are separated by the three cutane-
ous grooves on the midcheek: the palpebromalar groove (1), the naso-
jugal groove (2), and (3) the midcheek furrow [4]

laxity, and why at times, a superficial (subcutaneous) tempo-

ral lift produces better skin re-draping over the lower temple
and crow’s feet area than that achieved by a deep temporal
lift (sub-temporoparietal fascia composite lift).
Ptosis of the skin of the temporal region, which contrib-
utes to temporal hooding, can be corrected by an isolated
temporal lift, without necessarily requiring a brow lift.
Temporal hooding is the result of ptosis of the ROOF and
tissue layers one, two and to a varying extent, layer three of
the anterior part of the temporal region.
The absence of frontalis over the lateral brow contributes
to temporal hooding.
Attenuation of the periorbital septum over the lateral part Fig. 7 The preseptal space. IBTP inferior border of the tarsal plate
of the orbit allows further ptosis. (superior boundary), ORL orbicularis retaining ligament (inferior
The combination of ptosis of the midcheek tissue and par- boundary)
tial tethering by the retaining ligaments is responsible for the
gradual appearance of separate soft tissue segments delin- to the orbital rim, to where the orbicularis retaining ligament
eated by a series of cutaneous grooves (Fig. 5). (ORL) attaches below the rim and below the attachment of
The midcheek skeleton also undergoes aging changes that the arcus marginalis (Figs. 7 and 8).
have only recently begun to be appreciated for their impor- The roof of the preseptal space (composite layers one to
tant clinical consequences. There is a significant loss of pro- three) is the ‘anterior lamella’ of the lid. It is formed by the
jection of the body of the maxilla below the orbital rim in upward extension of the cheek SMAS investing the orbicu-
contrast to the prominence of the zygomatic body that laris oculi pars palpebrae.
appears not to regress. These changes of skeletal projection The floor of the preseptal space (layer five, the ‘posterior
are important contributors to the laxity and descent of the lamella’) is mainly formed by the septum orbitale, with the
medial cheek soft tissue (Fig. 6) [39]. lowest part formed by the inferior orbital rim (Fig. 8). The
The preseptal space of layer four is the central structure septum orbitale is anatomically divided into two parts: an
of the lower lid and it extends for several millimetres inferior upper, reinforced portion, where the septum is supported by
860
the capsulopalpebral fascia, and a lower portion, which is not
reinforced by the capsulopalpebral fascia. The lower part is
prone to distension, with bulging of the orbital fat over the
lowest part of the floor. With less support of the lower part of
the septum orbitale and possibly a small amount of resorp-
tion of the bone of the inferior orbital rim [40], there is a
greater tendency for it to weaken and allow the central lid fat
to bulge. One reason for the apparent thickness of the Asian
lower eyelid may be the large area of unsupported orbital
septum, which in the central part averages 3 mm longer in
Asian lids than it does in Caucasian lids [41].
Lower lid bags become prominent over the lid-cheek seg-
ment as the septum orbitale weakens and distends, bulging
over and then below the inferior orbital rim onto the anterior
surface of the maxilla. A small amount of prolapsed orbital
fat on top of the projection of the rim gives an exaggerated
Septum
orbitale
Preseptal
ORL
space
orbicularis
Prezygomatic oculi
space
Fig. 8 Anatomy of the lid-cheek region in youth (left) and with
advanced age (right). ORL orbicularis retaining ligament. With aging,
the lower part of the lid descends into the upper cheek
Fig. 9 Aging changes of the lower lid. The blue line overlies the infe-
rior orbital rim. In youth the cheek extends up over the orbital rim into
the lid, with a high lid-cheek junction. With aging the bulging lower lid
B.C. Mendelson and J.X. O’Brien
look, suggestive of a larger volume than is really present. At
the same time, the roof of the preseptal space (layer three)
undergoes distension and allows a slight descent of the
thicker part of the roof off the same bony prominence. On
account of the posterior angulation of the maxilla immedi-
ately inferior to the prominence, the descended part of the
upper midcheek loses projection. A thinner part of the roof is
now over the bony prominence. The magnification of these
small changes, caused by the prominence of the orbital rim
leaves the displaced lid fat projected as well as lower and at
the same time ‘revealed’ because the anterior lamella cover-
ing it is now thinner and the cheek below has retruded [4].
The shape and lower limit of descent of the lower lid bags
is defined by the ORL which is the anatomic structure
responsible for defining the palpebromalar groove [4, 42].
The position and shape of the lid-cheek junction changes
dramatically with aging as it descends into the lid-cheek seg-
ment. This bulging convex contour alters the shape of the
lower lid, giving the appearance of a ‘new’ lid-cheek junc-
tion below the bulge. It is still referred to as the lid-cheek
junction even though the ‘new’ lid-cheek junction contour
transition has moved off the anatomical lower lid and into the
territory of what had previously been the upper cheek [4].
Medial orbital fat bulges, in contrast to those laterally, are
located several millimetres above the inferomedial orbital
rim, held up by the unyielding character of the arcus margi-
nalis reinforced lower edge of the septum orbitale in this
location. Because of this and the deeper location of the sep-
tum, medial fat bulges initially forward, not inferomedially,
and this tends to exaggerate the depth of the nasojugal groove
(Fig. 9) [43].
• Lower lid bags are the result of herniated orbital fat, and
ptosis of the orbicularis oculi.
• The lower boundaries of lower lid bags are defined by the
tethering effect of the orbicularis retaining ligament.
fat extends down over the rim into the upper cheek, resulting in a low
lid- cheek junction
The Aging Face
Fig. 10 The aged midcheek. The cutaneous grooves and soft tissue
segments reflect the underlying anatomy
These well-defined boundaries are the nasojugal and pal-
pebromalar grooves.
Accentuation of the nasojugal and palpebromalar grooves
occurs at the lower borders of the lid-cheek segment. These
signs of aging are the product of changes that occur mostly
in layer four, at the lower boundary of the preseptal space,
compounded by recession of the maxilla [4, 44].
Malar mounds, also called malar bags, and double bags of
the lower lid, are the visible manifestation of aging changes
in and around the malar segment. The shape of malar
mounds, triangular with the apex medially, mirrors that of
the underlying prezygomatic space, being defined by the
same ligamentous boundaries (Fig. 10) [1, 4, 41, 42, 45].
The prezygomatic space overlies the body and maxillary
process of the zygoma [1], and is separated from the presep-
tal space of the lower lid superiorly by the ORL.
The roof of the prezygomatic space (layer three) is the
SMAS investing the orbicularis oculi pars orbitale, deep to
which is a thin layer of adherent fat quite distinct from the pre-
periosteal fat by its fine lobulation and distinct yellow colour.
This is the sub-orbicularis oculi fat (SOOF) (Fig. 8) [1, 4, 42].
The floor of the prezygomatic space (layer five) overlies
the origins of the three lip elevator muscles overlying the
inferior part of the bone (Fig. 11). Adhering strongly to this
area of bone is the preperiosteal fat that not only covers the
exposed bone, but it also extends inferiorly between the mus-
cles and covers the origins and bellies of the muscles for
some distance. The floor is lined by a thin transparent mem-
brane adherent to the preperiosteal fat and the muscles. As a
result, the floor of the prezygomatic space extends lower
than expected [1, 4, 42]. The boundaries of the space are
depicted in Fig. 12.
The boundaries of malar mounds are defined by the teth-
ering effect of the orbicularis retaining ligament superiorly –
separating the mounds from the lower lid bags, and of the
zygomatic ligaments inferiorly.
861
Fig. 11 Anatomy of the preseptal and prezygomatic spaces
Malar mounds are the result of laxity and ptosis of the
orbicularis oculi over the prezygomatic space. This ptosis is
largely the result of laxity of fixation above by the orbicularis
retaining ligament.
The nasolabial segment (see Fig. 5) is separated from the
laterally placed lid-cheek segment by the nasojugal groove,
and below that from the malar mounds by the midcheek fur-
row, a continuation of the nasojugal groove downward and
outward [4]. Fullness of the nasolabial fold, the medial side
of the nasolabial segment, is part of a complex change devel-
oping in concert with the development of these furrows [46].
The nasolabial fold has an upper and lower part. The upper
part is partially attached to the underlying maxilla where it
overlies the origins of the levator labii superioris and levator
labii superioris alaequae nasi. This attached upper part con-
tinues to the level of the alar crease. The major part of the
nasolabial fold overlies the vestibule of the oral cavity and
the buccal space and is accordingly mobile. Only the most
lateral part of this mobile segment has a direct fixation. This
is where the strong zygomatic ligaments (responsible for the
midcheek furrow), aided by the upper masseteric ligaments
suspend it from the body of the zygoma. The lower part of
the fold continues into the lower cheek beyond the oral
commissure where it contributes to the fullness of the labio-
mandibular fold as the buccal fat pad distends the lower bor-
der of the buccal space with age [1, 4, 46].
The nasolabial fold is separated from the medially placed
peri-oral region by the nasolabial crease, which, with aging,
develops into the nasolabial furrow [4, 46, 47].
The subcutaneous fat (layer two) in the nasolabial fold is
both thicker and more mobile than the subcutaneous layer
over the midcheek segments lateral to the midcheek furrow
[27]. Because of its thickness and defined boundaries, the
subcutaneous fat of the fold appears as a distinct entity,
862
Fig. 12 Boundaries of the prezygomatic space. ORL orbicularis retaining ligament, ZL zygomatic cutaneous ligaments
commonly referred to as the malar fat pad [47], which is a
misleading term because the malar fat pad does not overlie
the zygoma (malar segment) as its name suggests. It actually
overlies the maxilla [4, 42, 48].
The nasolabial crease is the result of two anatomical fac-
tors: (1) the abrupt transition of subcutaneous thickness
between the medial border of the malar fat pad and the lip
and (2) the mimetic muscle action via slips which insert into
the dermis of the crease [49]. At its superior extent, the
crease is accentuated by the action of the levator labii superi-
oris alaeque nasi, which also serves to elevate the lateral ala.
The middle section of the crease is deepened by the action of
levator labii superioris [49, 50]. The inferior extent of the
nasolabial crease is accentuated by the action of zygomaticus
major [46, 49, 51].
Flattening of the nasolabial fold in the setting of facial
nerve palsy [51–53] indicates that the action of the above-
mentioned muscles contributes not only to the nasolabial
crease, but also to the shape and apparent volume of the
nasolabial fold. Levator labii superioris, zygomaticus
minor, and zygomaticus major are all deep to the fold on
their course from the zygoma to the orbicularis oris.
Zygomaticus major contraction exaggerates the fold by
pulling the nasolabial crease beneath the fold, resulting in a
concertina effect [53].
B.C. Mendelson and J.X. O’Brien
The effect of SMAS traction to elevate the nasolabial fold
is to directly reposition the composite layer (layers one, two,
and three) of the fold and so it reduces the concertina effect
caused by the action of the lip elevators on the crease. This
dynamic further demonstrates the interplay between ptotic
tissue and structures tethering the dermis.
Compounding the aging changes in the nasolabial fold and
crease is the malar fat pad. Within the composite structure of the
nasolabial segment, which in other regions of the face behaves
as an en bloc structure with respect to ptosis, the malar fat pad
(layer two) independently descends with age on the plane super-
ficial to the SMAS-invested mimetic muscles [47]. As such, the
ptosis leading to increased volume and positional change of the
nasolabial fold occurs across two planes. Given the significant
contribution by the malar fat pad, correction of this alone may
obtain a major degree of improvement. Dissection of the under-
side of layer two (deep subcutaneous plane) off the thin SMAS
here can be readily performed (see Fig. 1).
• The nasolabial crease is defined by the dermal insertions
of the lip elevators, and these insertions have a tethering
effect on the nasolabial fold.
• The nasolabial fold and crease are accentuated with age
by ptosis of tissue layers one, two, and three over the
maxilla and the vestibule of the oral cavity.
The Aging Face
Fig. 13 Labiomandibular fold and jowl. The yellow dot overlies the
fixation provided by the mandibular ligament. This point is the anterior
edge of the jowl and the inferior extent of the labiomandibular fold
• The malar fat pad contributes substantial volume to the
nasolabial fold.
The jowl and labiomandibular fold appear with the onset
of facial aging. In this, they differ fundamentally from other
facial landmarks, such as the nasolabial crease and the lid-
cheek junction, the presence of which are integral to the shape
of the youthful face, although they deepen with aging [54].
The jowl and labiomandibular fold are the result of ptosis
of the roof of the premasseter space. The mandibular ligament
tethers the dermis at the anteroinferior corner of the space. In
youth, the (weaker) masseter cutaneous ligaments at the ante-
rior border of the space provide further fixation, but this fixa-
tion does not result in visible cutaneous tethering (Fig. 13).
The shape of the premasseter space reflects the shape of
the floor, which is based on the deep fascia investing the
masseter muscle (layer five) [7, 54]. The roof of the space is
formed by the SMAS investing the platysma (layer three) [1,
7, 28, 54]. The roof is lined by a membrane which reflects
deeply at the boundaries of the space and lines the floor as
well [54]. The boundaries of the space are shown in Fig. 14.
In the interval between the anterior ear cartilage and the
posterior border of the premasseter space, the SMAS is
firmly adherent to the underlying structures, particularly the
parotid capsule [28, 54]. This dense attachment extends for-
ward of the tragus for approximately 25–30 mm, then termi-
nates abruptly over the lower part of the masseter. In this
region, there is a major fusion of all the layers, which is
named the platysma auricular fascia (PAF). This broad area
of ligament is beneficial for surgeons as it supports fixation
sutures from the mobile SMAS anterior, to the fixed SMAS
(PAF) posterior. The lower posterior part of the PAF
863
Fig. 14 Premasseter space anatomy in youth. Anterior boundary:
Masseter-cutaneous ligaments (MCL), mandibular ligament (ML).
Posterior boundary: Fusion of the SMAS to the parotid capsule. Inferior
boundary: Membranous reflection overlying the mandible
overlying the trunk of the facial nerve immediately anterior
to the lower part of the tragus is the tympanoparotid fascia,
and has been called Lore’s fascia [55]. It is an excellent fixa-
tion point for platysma fixation sutures. The posterior border
of the premasseter space begins where this dense attachment
ends, just forward of the anterior edge of the parotid and well
beyond the posterior border of the mandible [54]. There is no
visible aging change here on account of the strong fixation
and the small amount of movement over this part of the
mandible. In contrast, there are major aging changes of the
anterior boundary of the premasseter space.
The lower masseteric cutaneous ligaments at the anterior
boundary of the space undergo considerable attrition, result-
ing in more laxity of the boundary and weakened attachment
of the platysma roof. The nearby mandibular ligament
remains strong and its tethering effect becomes more
apparent.
When significant aging changes are present, the buccal fat
may extend down so low as to bulge into and distend the
anterior boundary of the premasseter space (where it is
angled obliquely forward above the jowl extension). Buccal
fat in this area contributes to the heaviness of the labioman-
dibular fold and in cases of major descent may also contrib-
ute to fullness of the jowl (Fig. 15) [54].
It is the laxity of the superficial fascia (platysma) where it
overlies the jowl extension of the premasseter space immedi-
ately above the mandibular ligament that allows fullness of
the labiomandibular fold to develop. This laxity contrasts
864
Fig. 15 Anatomy of the aged premasseter space. Note the bulging of
the anteroinferior corner of the space producing the jowl. The buccal
space becomes distended allowing the buccal fat to extend over the
anterior edge of the masseter
with the labiomandibular crease, which defines the medial
extent of the fold and results from the tethering from the line
of fibrous adhesion between the fascia on depressor anguli
oris and the overlying dermis [54].
The jowl and labiomandibular fold are the end result of
ptosis of the composite tissue layers one, two, and three over
the premasseter space.
The labiomandibular crease results from the tethering
effect of the fascia of depressor anguli oris on the overlying
dermis.
Traditionally, it has been regarded that a subcutaneous
plane for facelifting is the safest plane on account of it being
remote from the facial nerve. However, the subcutaneous
plane is vascular, compared to dissecting within the ‘avascu-
lar’ soft tissue spaces, which are also safe spaces as there are
no facial nerve branches within.
Recontouring the face, rather than tightness of the skin, is
the objective of modern rejuvenation surgery. In fact, contour-
ing requires an avoidance of the flattening effect of excessive
skin tension. Contouring of the lower face can be achieved in
either of two ways. Indirectly, by re-draping the en bloc com-
posite flap following subSMAS dissection (layer 3) or directly,
by contouring of the subcutaneous layer using local plication
sutures following superficial subcutaneous dissection (layer 2).
Understanding the anatomy along the lower border of the
premasseter space is important for the surgeon. When the roof
B.C. Mendelson and J.X. O’Brien
of the premasseter space is tightened, the benefit extends well
inferior to the lower boundary of the space and beyond the
jowl into the upper neck, on account of the absence of liga-
mentous fixation of the entire lower boundary, i.e., between
the PAF posteriorly and the mandibular ligament anteriorly.
This is the reason why the limited dissection MACS lift [56]
and SMASectomy [57] procedures work well for lower face-
lifting. The avoidance of the risk of mandibular branch injury
is an additional bonus. Below the mandible, the platysma can
be similarly re-draped without the need for preliminary dis-
section using an external plication through layer 2, of the
mobile platysma to the fixed Lore’s fascia (PAF) [55].
Conclusion
An understanding of the concentric layered structure of the
facial soft tissues provides the basis for understanding the
effects of the aging process, and for a logical comparison of
the various planes used in facial rejuvenation procedures.
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57. Baker DC (2008) Lateral SMASectomy, plication and short scar
facelifts: indications and techniques. Clin Plast Surg 35:533–550
 Forehead and Brow Rejuvenation
Erik A. Hoy, Benjamin Z. Phillips, and Patrick K. Sullivan
1 Introduction
The forehead is often the first element of the face to show
aging [1, 2]. Since the hair-bearing eyebrow is the most obvi-
ous aspect of the forehead, procedures such as forehead lifts,
foreheadplasty, etc., have been referred in general terms,
simply as “browlifts” [2]. Gonzales-Ulloa first described
resuspension of the brow region through a coronal approach
in 1962 [3]. Subsequent authors have altered or refined his
approach to this area. Procedures to address the prematurely
aging brow are among the most commonly performed in
plastic surgery. In 2008, surgeon members of the American
Society of Plastic Surgeons (ASPS) performed over 42,000
surgical browlift procedures, and many of the 5 million cos-
metic Botox treatments and nearly 1.6 million soft tissue
filler procedures were directed at forehead rhytids and trans-
verse brow or glabellar creases [4]. Recent trends toward
minimally invasive procedures have led to the development
of endoscopic and other limited-length incisional approaches.
2 Anatomy and Consequences
of the Aging Process
2.1 Musculature
The motion of the brow is due in large part to the frontalis
muscles, which are joined to the occipitalis by means of the
galea aponeurotica. The frontalis is rare in that it is a skeletal
muscle that does not originate from, nor insert into, the bone.
The superior aspect of the frontalis muscles originates from
E.A. Hoy, MD (*)
Department of Plastic Surgery, Alpert Medical School
of Brown University, Providence, RI, USA
e-mail: erichoymd@gmail.com
B.Z. Phillips, MD • P.K. Sullivan, MD
Department of Plastic Surgery, Brown University,
Rhode Island Hospital, Providence, RI, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_61
this sheet of connective tissue. The lower half of the muscle
provides the majority of contraction and hence is responsible
for the elevation of the brows. This contraction exerts tension
across the orbicularis oculi muscle and subsequently on the
skin of the lower brow. As this skin elevates, transverse folds
form as the skin “accordions” upon itself. As Knize points
out, the temporalis ends laterally at the superior temporal
fusion line, which crosses the brow at the junction of the
middle and lateral thirds [5]. Therefore the vertical vector is
smallest on the lateral third of the brow, and this portion is
also the first to descend with aging. Also, Knize points out
that, in this lateral third, the orbicularis’ action on the brow
is unopposed by the frontalis, hastening the development of
ptosis in this area [5].
The orbicularis oculi muscles are brow depressors, acting
against the pull of the inferior edge of the frontalis. Though
these muscle fibers run at right angles to the frontalis for most
of the brow’s length, their strong sphincteric function is a
powerful brow depressor, and repeated contractions or hyper-
active tone can result in periorbital rhytids, aka “crow’s feet.”
The procerus is an antagonist to the frontalis: it lowers the
brow (and pulls the soft tissues of the upper nose superiorly).
It originates on the superior aspect of the nasal bones and
inserts bilaterally on the frontalis muscles. The medial brow
is pulled inferiorly by activation of the procerus muscle, and
over time a deep transverse crease may develop at the root of
the nose.
The depressor supercilii muscles are another antagonist
of the frontalis. They originate from the superior orbital rim,
just above the attachment of the corrugators. They pass
obliquely to insert on the dermis. The depressor supercilii’s
contraction results in oblique skin creases at the medial
aspect of the brow. They are not alone in this action; how-
ever, the corrugator’s oblique head and the medial orbicularis
oppose the frontalis, depress the medial brow, and help cre-
ate oblique skin creases.
The corrugator supercilii muscles, like the depressor
supercilii, originate from the superior orbital rims, in this
case the medial aspects, and pass medially to insert into the
867
868
undersurface of the dermis. Their contraction pulls the brows
medially, resulting in vertical glabellar creasing of the skin.
Hyperactive corrugators result in deep creases that are diffi-
cult to address in vertical browlifting procedures alone, as
the pull is along the axis of the crease and perpendicular to
the muscle fibers responsible for it.
2.2 Motor Innervation
As in the rest of the face, the facial nerve (Cranial Nerve VII)
is responsible for movement of the mimetic muscles of the
forehead and brow. Specifically the frontal branch, as the
most superior branch of the facial nerve, passes from its
divergence from the main body of the nerve in the parotid and
exits the gland superiorly between the deep and superficial
lobes. The frontal branch courses from a point 5 mm below
the tragus to a point 15 mm above the lateral brow. Over the
zygomatic arch, it is found about 2.5 cm lateral to the lateral
canthus, placing it halfway between the lateral canthus and
the inferior helix where it is particularly vulnerable to care-
less dissection in browlift procedures [6]. Care must be taken
to avoid any traction on this branch by tenting the skin and
soft tissues over the elevator or scope during dissection from
above in the plane of the deep temporal fascia.
2.3 Sensation
Sensory innervation to the brow is by means of branches
from the V1 distribution of the trigeminal nerve (Cranial
Nerve V). Specifically, the paired supraorbital and supra-
trochlear nerves supply the lateral and medial forehead,
respectively. The supraorbital nerves exit from the supraor-
bital foramen an average distance from the midline of
2.42 ± 0.04 cm females and 2.56 ± 0.05 in males [7]. They
then split into superficial and deep branches to supply the
forehead. The deep division supplies the frontoparietal
region and can be injured along its course from the main
nerve trunk, where it runs superiorly between the galea and
periosteum, pierces the galea 2–2.5 cm above the orbital rim,
and continues superiorly within 1–2 cm of the temporal
fusion plane. If this nerve branch is injured, it is often sec-
ondary to traction injury with the dissector or to transection
by the coronal incision and results in paresthesia over the
temporoparietal scalp. The superficial branch is shorter,
more medial, and less often injured in browlifts. The superfi-
cial branch supplies the medial brow, medial forehead, and
anterior hairline.
Attaining an aesthetic postoperative result depends on
preoperative planning. An organized, logical analysis of the
aged brow is of paramount importance. Understanding the
patient’s concern with their appearance, and matching
E.A. Hoy et al.
achievable results to realistic patient expectations, is the core
of aesthetic surgery. As the evolution of procedures for fore-
head rejuvenation illustrates, this has not always been pos-
sible. Early attempts at forehead rejuvenation involved
elevating the eyebrow as a single aesthetic unit. However,
with refinements in analysis and techniques, the brow is now
usually addressed in terms of the medial, middle, and lateral
thirds. Often, the lateral third descends earliest and to a
greater extent [1, 2, 8, 9]. This lateral third not coincidentally
is the area that usually needs the majority of superior reposi-
tioning in the browlift.
3 The Ideals of the “Aesthetic Brow”
Multiple authors have studied the favorable brow position
and orientation, including the work by Westmore [10], Cook
et al. [11], Connell et al. [12], Matarasso and Terino [13],
McKinney et al. [14], and Gunter and Antrobus [15]. Most
authors acknowledge that the aesthetic ideal has changed
over time. Westmore proposed that the aesthetic brow had
the following attributes: a medial brow that began at the
same vertical intercept as the medial canthus and ending lat-
erally along an axis connecting the nasal ala with the lateral
canthus and medial and lateral endpoints along the same
horizontal axis with a peak directly above the lateral limbus
[10]. However, it is more aesthetically pleasing to most
patients and surgeons to achieve a final brow orientation with
a more elevated lateral third relative to the medial and middle
thirds of the brow.
More recently, authors have tried to ascribe more quanti-
tative attributes to the ideal brow [12–14]. Namely, the brow
should begin medially directly at the caudal aspect of the
superior orbital rim. The superior portion of the brow should
be 1 cm superior to the orbital rim and 5–6 cm inferior to the
hairline [16]. Additionally, the brow should be 1.6–2.5 cm
above the eyelid crease. The superior peak of the brow should
lie at the juncture of the middle and lateral thirds, lateral to
the location described by Westmore.
More recently, Gunter and Antrobus reviewed pre- and
postoperative photos of a cohort of his patients in his cos-
metic practice and compared their brow position versus that
of a number of fashion models in print magazines [15]. They
found that the patients tended to have flatter brows that
started medial to, peaked more lateral to, and ended more
inferolaterally than those of the models studied [15]. They
therefore refined the ideal brow to include the periorbital
structures, since intuitively, more attractive periorbital anat-
omy either enhanced an attractive brow or helped to compen-
sate for the less attractive one. By their specifications, the
brow should lie along a slightly inclining axis when viewed
from medial to lateral. The remaining findings, which will
not be discussed further here, were an upper lid which
Forehead and Brow Rejuvenation 869

overlies the iris 1–2 mm, a more vertically orientation of the

medial upper lid versus the lateral aspect, an upper lid crease Superomedial
which parallels the lash line and does extend toward the mid- osteoperiosteal ligament

line beyond the medial canthus nor laterally beyond the lat- Superolateral
eral orbital rim, no or minimal scleral show below the iris, osteoperiosteal
ligament
and finally, a smoothly arcing lower lid with the meniscus at
the lateral limbus [15].
A cautionary note should be mentioned here: these “ideal”
brow concerns are for the female patient. The male eyebrow
has been less studied [17] and has several key differences.
First of all, the male brow should lie at the level of the supe-
rior orbital rim and is less arching than the female brow. Still,
the peak should lie at the junction of the two lateral thirds.
Unlike other areas of the face, bony changes play little if
any role in aging of the forehead and brow. That being said, Fig. 1 Superomedial and superolateral ligamentous attachments of the
there is a spectrum of orbital rim anatomy seen in patients, as brow shown in the subperiosteal space. The superomedial structures
Barton points out in his book [2]. The superior orbital rim average 10.8 mm above the supraorbital rim and 13 mm from the mid-
line. The superolateral structure averages 10.3 mm above the supraor-
may take the form of a gradual transition from orbital roof to
bital rim and 23 mm from the midline
inferior brow, with its details masked by profuse orbital and
periorbital fat. Alternatively, some patients may have a more
severe appearance of their superior orbital rim, relatively
devoid of upper lid and periorbital fat to disguise the bony
Inferomedial
anatomy [2]. Whatever the configuration, in terms of bony osteoperiosteal ligament
anatomy, what one sees is what one gets: bony anatomy is
Supraorbital
rarely changed in forehead rejuvenation, though volume res- neurovascular
toration in the form of autologous tissue transfers such as fat bundle
grafting has been used to good effect by the senior author.
Increasing laxity and ptosis of the soft tissues of the brow
are responsible for the stigmata of aging in this area. Since
the descent of the brow is a soft tissue process, attempts at
rejuvenation involve release, redraping, and resuspension of
these tissues, with occasional resection of excess skin.
Difficulty in obtaining precise control of the medial, middle,
and lateral thirds of the brow spurred further studies into the
anatomy of this area.
The senior author recently published his work in dissecting
24 hemi-foreheads, with close attention to the ligamentous Fig. 2 The inferomedial ligamentous attachment is at the level of the
attachments of the brow [18]. Notable findings included mul- orbital rim and averages 2.6 mm from the midline just medial to the
tiple ligamentous structures analogous to the suspensory liga- supraorbital neurovascular bundle
ments of the mid- and lower face. In the subperiosteal plane, a
superomedial ligamentous attachment was found to originate was inserted to the superficial temporal fascia, as described by
on average 10.8 mm above the supraorbital rim and 13 mm Knize [19, 20]. Without release of this structure in its entirety,
from the midline. Also in the subperiosteal plane, a ligamen- the lateral brow cannot be optimally elevated. The short and
tous attachment originated an average of 10.3 mm above the stout fibers of the retinaculum cutis help secure the skin tightly
supraorbital rim and 23 mm from the midline (Figs. 1 and 2). to the frontalis muscle, and in dissection, no definite ligamen-
Though these attachments appeared to serve a similar purpose tous attachments were encountered.
to those of the midface, the ligamentous thickenings of the
forehead are broad based. They continued from the bone,
pierced the periosteum, and inserted into the frontalis muscle 4 Preoperative Planning
and the tightly adherent overlying skin. Also dissected out was
a long and broad ligamentous structure which extended from The interrelations between development of brow ptosis and
the lateral aspect of the supraorbital rim and extended laterally changes in the upper eyelid are notoriously misunderstood
to the superior aspect of the lateral orbital rim. This structure by patients presenting for rejuvenation of the upper third of
870
the face. In addition to a systematic approach to presurgical
examination of these patients, a series of photos and an exam
in front of a large mirror are vital in evaluating and instruct-
ing prospective patients in what to expect from their browlift
procedure. Preoperative photographs should include the
standard anterior-posterior, oblique, and lateral views, as
well as close-up views of the periorbital area in repose with
eyes open and closed, smiling, with eyes tightly closed, and
with full corrugator/procerus and frontalis muscle contrac-
tions. These views, along with a dynamic exam in front of a
large mirror, should help educate the patient and surgeon
about what features of aging are present and which proce-
dures are indicated. These images should be printed and
readily available during the surgical procedure for easy refer-
ence, as the facial anatomy is easily distorted in the supine
position. As always, the patient is examined again on the day
of surgery, in the preoperative area, and after observing the
brow in motion and at rest, the transverse brow and glabellar
creases are marked. Preoperative markings are also placed if
a blepharoplasty is planned. Typically, coronal, limited-
length, or endoscopic access incisions are marked on the
operating table.
5 Patient Selection: Indications
While the indications for forehead lift and browlift, plus the
possible need for upper blepharoplasty, are concepts that are
sometimes poorly understood by patients, they are relatively
straightforward. These include ptosis of the eyebrows, espe-
cially when portions of the eyebrow skin descend below the
superior orbital rim and thus give the impression of excess
upper eyelid skin. This may occur as a normal consequence
of the aging process, but is often seen with bilateral or one-
sided frontalis dysfunction, as in the case of Bell’s palsy.
These processes differ in regard to the appearance of the
forehead skin, with natural aging and normal frontalis func-
tion resulting in transverse skin rhytids, whereas the paretic
brow is typically ptotic but without wrinkling due to
decreased frontalis tone. Repetitive contraction of the corru-
gator muscles, procerus, and orbicularis oculi muscles can
lead to vertical or transverse glabellar creases, and “crow’s
feet,” respectively. When mild, these conditions can be
treated with Botox for improved contour and symmetry [21].
Moderately deep creases may be addressed with a variety of
alloplastic filler materials, which are not addressed in this
chapter. However, deep creases and skin excess are best dealt
with surgically by means of browlift, with or without dener-
vation of the muscles of the brow and resection of the pro-
cerus and corrugator muscles [22]. While the use of chemical
denervation with Botox and soft tissue augmentation with
non-autologous fillers will not be discussed in further detail
here, the reader is referred to an excellent article on the topic
E.A. Hoy et al.
[23]. It is the senior author’s preference to reestablish soft
tissue volume in the brow with autologous fat grafting, where
indicated. Results with and without this adjunctive proce-
dure are presented below.
6 Aging of the Brow and Periorbita
As alluded to above, it is sometimes difficult to discern
where the aged brow ends and where the aging upper lid
begins. Often, one element is the key feature of the aging
process and is compensated by another – and one or both
need to be dealt with to effectively rejuvenate the face’s
upper third. As brow skin descends and abuts and then dis-
places upper eyelid skin, the patient may unconsciously
develop visual field limitations superiorly. To counteract
this, they will activate the fibers of the frontalis muscle to
elevate the brows when the eye is open, thereby lifting some
of this soft tissue excess out of the upper visual field. The
result is a ptotic upper lid which may or may not be ade-
quately compensated by brow elevation and a high-arched
and superiorly displaced hair-bearing brow. Transverse
rhytids are also common in this case of increased tone of the
frontalis muscle.
An important principle of rejuvenation of the upper third
of the face is this: if both of these areas are problems which
are not addressed, the patient will be unhappy with their
postoperative appearance. This must be borne in mind when-
ever a patient states, “I just want my eyes done” or “I just
want my eyebrows lifted.” The patient may not realize the
full extent of their upper lid ptosis because of a compensa-
tory elevation of the brow. Showing such a patient their
appearance in repose can help illustrate the actual anatomy
in the area, without distorting input from the frontalis.
However, if this relationship is not appreciated by the patient
and surgeon prior to blepharoplasty, the brows will descend
postoperatively, when this compensatory mechanism is no
longer needed. Despite the upper lid skin excision, a descend-
ing brow can offset the rejuvenative effects of the upper
blepharoplasty. Understanding the anatomy of the brow and
the etiology of the aging process is vital in achieving the
desired results in foreheadplasty and browlift.
7 Objectives
As with much of aesthetic surgery, the aims in rejuvenative
procedures for the brow are simple, and the difficulty lies in
their implementation. The main goal is to restore a more
youthful appearance to the brow region, without “overplay-
ing the hand” and conveying an overly lifted appearance. As
Barton states in his book, while the depressed brow in unaes-
thetic, it is natural. The elevated brow is a postsurgical look
Forehead and Brow Rejuvenation
[2]. The goal is to elevate the elements of the brow smoothly
and to the correct extent. As discussed above, the lateral
brow typically needs to be lifted more than the remainder of
the brow. In most patients, the medial brow needs little if any
elevation. Elevation of the medial brow conveys a “surprised
look” [24]. In lifting and redraping the brow, transverse lines
should be softened, and if necessary autologous or off-the-
shelf fillers can be employed to fill deeper creases. Hair fol-
licle concentration and thickness should be preserved, and
the hairline location should be either preserved or lifted to a
minor extent. If indicated, an upper blepharoplasty should be
performed to excise excess upper eyelid skin prior to redrap-
ing of the brow. Whenever possible, the tenets detailed above
for the aesthetic brow should be the goal. That being said,
however, the appearance of the row and upper lids can vary
greatly between individuals and should be tailored to best
suit the patient.
8 Approaches
1962 Gonzales-Ulloa Coronal incision for forehead/browlift [3]
1978 Ortiz-Monasterio Combined rhytidectomy and coronal
browlift procedures [25]
1994 Vasconez Endoscopic approach to browlift [26]
1996 Knize Limited incision technique for browlift [5, 27]
Gonzales-Ulloa first described the coronal approach in
an isolated procedure for elevation of the forehead and
brows. Ortiz-Monasterio then incorporated this as an ele-
ment of his rhytidectomy technique in 1974, and many
others followed suit. Two variations on this long coronal
incision have become commonplace, the standard coronal
incision with curvilinear deviations such that the incision
is always 6–7 cm posterior to the hairline and a modified
anterior hairline incision. This modified anterior hairline
incision is located more posterior along the desired vectors
of the temporal lift. This incision is the senior author’s
preference in those patients with a relatively high hairline
or anteriorly thinning hair. However, either approach
results in a rather long scar, across the whole of the tempo-
roparietal scalp.
The next major advance in surgical approaches arrived
with the advent of endoscopy in plastic surgery. Knize fur-
ther refined these approaches with a limited scar technique
for brow, temporal, and upper eyelid rejuvenation. These
minimally invasive techniques are, in most cases, equally
potent in terms of brow elevation versus the coronal
approach, with a reduced incidence of scalp paresthesias or
alopecia. Though fewer surgeons are relying on the coronal
approach, it is still the technique used by most plastic sur-
geons despite these shortcomings. We present the senior
author’s preferred approach to endoscopic brow rejuvenation,
871
with long-term results, and detail the limited situations in
which a short scar is employed. Because of the power of the
endoscopic lift, and the well-hidden scars, coronal incisions
are very seldom needed.
9 Operative Technique
In the senior author’s clinical cases, the results of this ana-
tomical study of the ligamentous attachment positions are
applied to preserve them with both open and endoscopic
approaches. After the initial incisions are made 2 cm poste-
rior to the hairline, dissection is performed inferiorly in the
supra-periosteal plane toward the supraorbital region. Care is
taken to preserve the medial brow retaining structures.
Dissection then proceeds from lateral to medial across the
superior orbital rim. The lateral retinacular ligament is
released lateral to the supraorbital nerve, avoiding any trac-
tion on the nerve. Adequate exposure for resection of the
medial corrugators and procerus muscles is obtained by dis-
secting a central tunnel between the two superomedial retain-
ing structures. Preserving these medial retaining structures
allows the surgeon to control the position of the lateral brow
while helping to prevent over-elevation or lateral spreading
of the medial brow in both endoscopic and open procedures.
This is one element in preventing the “surprised look” in
these patients.
Once the dissection is completed, the process of brow
elevation and suspension can begin. Osteal tunnels are cre-
ated with a small drill, which provide strong cleats through
which to pass the suture. In this way, implanted materials
such as screws, posts, or anchors which could become pal-
pable are avoided. The suspensory sutures consist of per-
manent (4-0) nylon sutures in the deep dermal plane. Three
passes of the suture are made through the deep dermis,
aponeurotic tissues, and galea for each point of fixation.
Using a rocking motion, the first tie is placed so that the
knot will not slip as subsequent throws are placed. Care
must be taken to avoid placing too much tension on these
sutures when tying.
10 Closure
The closure of the endoscopic or limited-length incisions
within the hair is accomplished with a skin stapler. These
incisions are everted properly, and the scars heal well with
the advantages of ease of removal and without the need to
tie or remove sutures among the hair follicles. Incisions
that must be located nearer to the hairline, and in thinner
hair by necessity, are closed with running 5-0 nylon sutures
and W-plasty for camouflage of the healed scar.
872 E.A. Hoy et al.

Fig. 3 Preoperative (a–c) and postoperative (d–f)

photographs of a patient who underwent endoscopic a d
forehead rejuvenation. Facial and neck rejuvenation
was performed with upper lid blepharoplasty.
Forehead and glabellar rhytids were addressed. The
medial retaining ligamentous attachments were left
intact to control the position of the medial brow

b e

c f
Forehead and Brow Rejuvenation
11 Peri- and Postoperative Care
Postoperative care of the patient begins on the operating
table after the browlift procedure. First, emergence from
sedation should be smooth, with good communication
between the surgeon and anesthesiologist, and without
hypertension, coughing, or gagging. With intraoperative
careful attention to hemostasis and postoperative strict
adherence to activity instructions, the incidence of hema-
toma should be rare. As with rhytidectomy, patients should
be instructed to sleep with their head elevated and their neck
extended slightly. The senior author also instructs his patients
to place a wedge beneath the head when sleeping. NSAIDs
and anticoagulants should be held for at least a week after
brow rejuvenation. Finally, ensuring good communication
between the surgeon and patient throughout the process
increases cooperation and helps to achieve better outcomes.
12 Avoidance of Complications
Complication rates for brow rejuvenative procedures are simi-
lar to those seen after rhytidectomy. Fortunately, in our experi-
ence, they have been rare. Though postoperative hematomas
do occasionally occur, we are extremely cautious about bleed-
ing and make absolutely certain the field is dry before closure.
The complications, though infrequent, should be recognized
early and treated. This includes draining hematomas as soon
as they are recognized. Seromas have not been encountered,
but would also be treated with drainage or aspiration. Infection
is treated with intravenous antibiotic coverage for skin flora
and drainage if necessary. We use perioperative antibiotics
routinely and have not had infections as a problem. Lastly,
necrosis of the brow is exceedingly rare, but would be man-
aged with topical antibiotics to prevent superinfection.
13 Results/Cases
Preoperative (Fig. 3a–c) and postoperative (Fig. 3d–f) ante-
rior and right lateral oblique photographs of a patient who
underwent endoscopic forehead rejuvenation. Facial and
neck rejuvenation was also performed with upper lid blepha-
roplasty. Forehead and glabellar rhytids were addressed. The
medial retaining ligamentous attachments were left intact to
control the position of the medial brow.
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the browlift. Clin Plast Surg 5:167
26. Vasconez LO, Core GB, Gamboa-Bobadilla M, Guzman G, Askren
C, Yamamoto Y (1994) Endoscopic techniques in coronal brow lift-
ing. Plast Reconstr Surg 94:788–793
27. Knize DM (1996) Limited incision forehead lift for eyebrow eleva-
tion to enhance upper blepharoplasty. Plast Reconstr Surg 97(7):
1334–1342
 Suspension Techniques in Aesthetic
Surgery of the Face
Ithamar Stocchero
1 Introduction
Every surgical technique is the consequence of need. This
happens regarding any situation: pain, tumors, laxity and,
indeed, vanity. Concerning facelift surgical techniques, in
the past two decades plastic surgeons have looked for more
natural results, less invasive surgeries, suitable recovery, low
stigma, shorter scars, and low risk; besides which, patients
are interested in a quick return to their jobs, carrying on as
normal, and not wanting to give up their habits.
Although the so-called classic facelift with superficial
musculo-aponeurotic system (SMAS) resection and an
extensive undermining may give better and more long-lasting
results, the recovery time, morbidity, risk of overcorrection,
and presence of long scars do not seduce a significant num-
ber of potential patients. In fact, most people want to have no
more than a pleasant appearance; they feel happy with the
simple comment that they are looking good for their age. If
the surgeon performs a procedure with a painless postopera-
tive course, patients will not be afraid to undergo it. As the
respected surgeon Thomas Biggs used to say, it is time to
have “the most for the least.”
Suspension techniques for facelift are considered rela-
tively new options in the plastic surgeon’s arsenal, although
they have been developed over the past 20 years. It takes time
to persuade patients and surgeons that simpler procedures
may offer good results.
We recently discovered [1] that, in fact, the first publica-
tion mentioning a facelift suspension is 70 years earlier than
we knew. How much different facelift history would have
been if the paper by Virenque [2] could have been dissemi-
nated. The relevant points perceived since that time are the
I. Stocchero, MD
Head of Plastic Surgery, Centro Médico Viver Melhor,
São Paulo, Brazil
e-mail: dr.ithamar@vivermelhor.com.br
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_62
better knowledge about the SMAS [3] and the retention liga-
ments of the face [4].
It is important to differentiate plication from suspension:
plication sutures neighboring structures; suspension anchors
structures that are far one from another. Suspension is stron-
ger, modifying a vector of traction. Since a good result in
rhytidoplasty is essentially the final effect of traction vectors,
it makes all the difference.
Some fundamental points must be considered regarding the
suspension in facelift. The most performed procedures are static
suspensions, when a suture is placed fixing two points in a
definitive position, not allowing a change in the final disposition
of structures. The molding will stay as the surgeon has decided.
There is the option of a dynamic suspension, when the action of
the muscles of facial expressions will act along a large purse-
string suture of SMAS. In this technique the surgeon defines the
points that will limit the whole area where the suspension will
be established: this is the Roundblock SMAS Treatment [5, 6],
when the anterior and inferior portion of the suture are done in
front or below the ear, leaving the muscles free to stabilize in a
final and natural situation, and the superior and posterior portion
of the ring suture are done stably, anchored in the temporal and
mastoid areas. This dynamic accommodation will preserve the
patients’ own facial expressions.
All of the techniques of SMAS suspension usually
avoid an extensive undermining, maintaining the attach-
ments of skin to deeper structures, preserving blood sup-
ply and innervation, allowing the facelift in smokers,
elderly patients, and even in people with certain chronic
diseases, since it is a quick procedure that respects the
integrity of most anatomical structures. When the traction
is carried out, it acts by repositioning the facial volume in
a compact loop suture, elevating en-bloc the fallen struc-
tures of the face such as jowls and malar fat pads, and even
improving the neck contour. These suspensions bring the
skin toward the ear, reducing the dead space and the ten-
sion in the skin suture, allowing a short-scar facelift to be
easily performed.
875
876 I. Stocchero

2 Surgical Techniques

2.1 Virenque (1927)

Thanks to a recent paper by Tonnard and Varpaele [1], this

first suspension technique is now known, and is quite similar
to today’s techniques, with a limited undermining and three
suspension sutures at the parotid fascia [2] (Fig. 1).

2.2 Stocchero Criss-Cross [7] (1992)

Classic incisions and undermining, with two tension sutures: one

suspending the malar region and anchoring at the temporal fas-
cia, and the other tractioning the platysma to the mastoid area.
The fact that there are only two vectors limit the results (Fig. 2).

2.3 Duminy and Hudson [8] (1997)

Incision just ahead of the ear, small undermining, and two

suspending sutures: one from the temporal fascia toward the
angle of the mouth, and other from the temporal fascia
toward the angle of the mandible.
Fig. 1 Virenque technique

2.4 Saylan [9] (1999)

An incision in front of the ear, contouring the ear lobe, with

a moderate undermining. Two sutures are made. The first one
is anchored to the periosteum of the zygoma and extending
to the platysma muscle, at the mandibular angle. The second
suture begins at zygoma and bites the parotid fascia and the
SMAS of the lower face obliquely.

2.5 Stocchero RBST Open

and Closed (2001)

A classical incision and undermining is performed. The SMAS

is bitten in a purse-string suture that will contour the ear, anchor-
ing the structures of the face to the temporal area [5]. Over time,
the incision changes to an inverted “Ω” (omega) around the ear
and small undermining [6] in the open technique (the closed
technique consists of one incision at the sideburn and a small one
behind the ear).

2.6 Tonnard and Verpaele MACS Fig. 2 Criss-cross technique

Lift [10] (2002)

An inverted L-shaped preauricular incision begins at the begins with a bite taken deep down to the temporal bone, to
inferior limit of the sideburn, with small undermining. Two include the deep temporal fascia; a second purse-string
suspension purse-string sutures are performed: the first one suture will be performed, ahead and parallel to the first.
Suspension Techniques in Aesthetic Surgery of the Face
Fig. 3 SAFE lift technique
A third purse-string suture may be executed, beginning at
the anterior part of the deep temporal fascia toward the
malar fat pad.
2.7 Isse SAFE Lift [11] (2005)
The Sub-Auricular Fixation, Extended (SAFE) lift is a tech-
nique for a stronger, secure, and “safe” suturing suspension
of the SMAS and platysma muscle to the fixed pericranium
and deep temporal fascia at the inferior temporal crest,
behind the superior portion of the auricle (Fig. 3).
2.8 Zimman Suspension [12] (2006)
There are three vectors of suspension, all them based in the
temporal fascial anchorage, just above the auricle. The inci-
sions of the skin will vary according the intended traction
and the amount of skin.
2.9 Marchac Monobloc [13–15] (2008)
Marchac reported U-shaped incision in the temporal area and
surrounding the ear. The suspension is made as the
Roundblock SMAS treatment, referred to by the author as
monobloc suspension.
877
2.10 Van der Lei PRS [16] (2009)
An inverted L-shaped prehairline and preauricular incision
contouring the ear lobe is performed, with small undermin-
ing. Excision of a strip of SMAS at the level of zygomatic
arch is done and the gap is sutured. Two suspension sutures
are performed beginning at the temporal fascia area as in the
MACS lift.
3 The Author’s Preferred Technique
3.1 The Roundblock SMAS Treatment
3.1.1 Anesthesia
General anesthesia or monitored conscious sedation with
local anesthesia is determined during the surgeon’s office
interview, considering the patient’s degree of anxiety.
3.1.2 Position/Markings
The patient is placed on the operating table. With a finger the
surgeon slides the facial skin toward the ear, simulating the
intended result. With a waterproof marker a dot is drawn at
the nearest point of the sideburn hairline, where the finger
still maintains the desired result. Repeating this maneuver
four or five times a dotted line is drawn around the ear, deter-
mining the minimum undermining to achieve the result.
The hair, head, and face of patient are carefully washed
with chlorhexidine, in a basin, leaving the antiseptic solution
in the hair to allow the head left over the sterile drape to stay
free. This enables the surgeon to move it right and left, and to
extend the neck.
If under general anesthesia, a 1:250,000 epinephrine-
saline solution is injected in the marked area, around the ear,
and in the submental and neck areas. If under local anesthe-
sia, a 0.5 % lidocaine solution is used together with a vaso-
constrictive agent.
3.2 Details of Procedure
3.2.1 Open RBST
The operation usually begins with liposuction of the sub-
mental region and neck, using a 3-mm incision behind the
chin. If needed, platysma bands are treated following this
procedure. On completion, an inverted-omega incision is
made contouring the ear, starting with a zigzag beveled inci-
sion about 3 mm above the border of the sideburn, in order to
protect hair follicles, and finishing transverse behind the ear,
in a projected line that passes above the tragus.
The previously-marked area is undermined at the subcu-
taneous plane. Pinch tests pulling the SMAS are executed to
confirm whether the tissues will allow for good traction, by
bringing the skin together (if this is not possible, additional
878 I. Stocchero

Fig. 5 Open RBST facial plication

Fig. 4 Open RBST facial plication

undermining may be required). Next, the risorius-masseter

zone is exposed, in addition to the cranial portion and the
mandibular insertion of the platysma muscle. Regardless of
the technique used there will be an overlapping of muscles in
this area; it is indeed convenient to restore volume.
At this time the purse-string suture is performed; it is eas-
ier to begin from behind the ear toward the neck and face. In
the mastoid fascia there will be no tissue lifting, since it is a
strong and fixed area. The traction begins to raise the tissues
as soon as the platysma muscle is reached. The bites must
not be close to one another; it is important to leave a 2-cm
space between them to permit imbrication of tissues. Before
each bite, it is appropriate to choose the best traction vector
by pulling the SMAS and then evaluating the changes that
occur in the patient’s face. A 45° insertion of the needle will
provide a stronger and safer suture, hence assuring a better
traction. The plication stops at the border of the sideburn
(Figs. 4 and 5). At this moment the surgeon must pull up this
semicircular suture to assure that the intended result is being
achieved, and that an effective vertical volume reposition has
been obtained (Fig. 6). Fig. 6 Traction after facial plication
Suspension Techniques in Aesthetic Surgery of the Face 879

Fig. 7 Stocchero’s needles

Fig. 9 Needle already passed

Fig. 8 Needle already passed

With the author’s needle (Fig. 7), a simulation of the best

trajectory is applied above the head, at least 2.5 cm higher
than the ear.
Once the ideal path is realized, the needle is passed deeply,
entering the anterior limit of the sideburn incision and directed
toward the limit of the retroauricular incision. The needle Fig. 10 Thread already pulled
must be passed in the galeal and deep muscular planes. After
arriving in the posterior area, the thread is passed through the
needle hole (Figs. 8 and 9) and the needle is pulled toward the The thread that sustains the SMAS-platysma must allow
front (Fig. 10). The thread must be strongly tied. Only then is muscular action along the stitch so as to offer a natural
the knot complete (Figs. 11 and 12). The purse-string suture expression to the patient, with a smooth and progressive
is then performed (Fig. 13). adaptation. It is desirable to leave this suture without addi-
For those who may be afraid of using the needle described, tional stitches in its anterior area, so that the facial muscles
it is perfectly feasible to achieve the same results by per- may act in a dynamic fashion and adapt to the movements of
forming a two- or three-step suture in the hairy area. the face.
880 I. Stocchero

Fig. 11 Knot already done

Fig. 13 Open RBST final, after traction

After this procedure, a large amount of skin around the

ear is ready to be excised. It is important to avoid
excessive tension in the skin suture. Drains are usually
unnecessary.

3.2.2 Closed RBST

Usually performed under local anesthesia associated with
monitored conscious sedation, this technique is an option
for those who desire a quick surgery and recovery, and
who accept the natural limits regarding results. It may be
very helpful when combined with an endoscopic facelift.
Marking and disinfection are conducted as previously
described. An incision is made at the sideburn and the
author’s needle is passed in the marked dots, biting the
SMAS and performing a circle toward the mastoid area,
reaching the postauricular region, where a small incision
is made, allowing the needle’s tip to appear. The thread is
Fig. 12 Knot already done passed through the needle’s hole and pulled back. The
Suspension Techniques in Aesthetic Surgery of the Face 881

Fig. 14 Closed RBST passing thread inferiorly

Fig. 15 Closed RBST passing thread superiorly

needle is passed from front to behind again, now in the

portion above the ear, deeper to hair follicles, at the mus-
cular level, the needle’s tip emerging at the same retroau-
ricular incision and bringing the remaining thread to the
sideburn incision. The thread is then tractioned and tied
(Figs. 14, 15 and 16).
Sometimes it is necessary to perform a superficial dissec-
tion with a cannula to treat some dips. It may be also neces-
sary at the sideburn and preauricular area to reseat a triangle
of skin to promote an adjustment. Some excess skin will
remain ahead of the ear and earlobe, which will settle in 2 or
3 weeks.

Fig. 16 Closed RBST final traction

882 I. Stocchero

4 Results

Case 1 Preoperatively and 6 months postoperatively.

Suspension Techniques in Aesthetic Surgery of the Face 883
884 I. Stocchero

Case 2 Preoperatively and 3 years postoperatively

Suspension Techniques in Aesthetic Surgery of the Face 885
886
5 Complications
After having performed more than 400 facelifts with this
technique, only one major complication was seen: a superfi-
cial skin necrosis in a patient who was a smoker and had a
previous car accident with injury of the facial artery on the
same side. It resolved spontaneously, and not even a scar
revision was needed.
Minor complications included a hematoma that was
drained bedside in a patient with Von Willebrand disease.
Expressive bruising was the most common complication,
occurring in 4 % of cases.
Ear lobe swelling occurred in 3 % of cases, consequent to
a very tightened suture near the ear. Recovery was gained in
1 week.
There were no cases of nerve damage.
Pain surrounding the ear is a common complaint that is
treated with analgesics.
6 Informed Consent
Usually, consent is given in Portuguese and consists of three
different printed forms:
1. General Orientation: Discusses what may occur in any
plastic surgery procedure; for example, scars, asymmetry,
surgery limits, false expectations, and medicine
interactions
2. Important Topics: Discusses the risks of any surgical pro-
cedure (death included), the possibility of revision surger-
ies and two-stage surgeries, and defines revision surgery
and staged surgery
3. Rhytidoplasty Surgery Orientation: Discusses specific
topics regarding the surgery, what is expected, what to
take to hospital, preoperative and postoperative restric-
tions. Regarding suspension facelift the patient is made
aware of pain around the ear; bruising that may take 3
weeks to disappear; importance of using sun blockers for
about 2 months. For 3 weeks driving and exercise is disal-
lowed, after which treadmill and bike exercises are
allowed; after 6 weeks everything is possible. Smokers
are restricted no smoking only for 24 h.
Arriving at the hospital, the patient must confirm and sign
that he/she was adequately informed about procedures.
I. Stocchero
7 Pearls and Pitfalls
Pearls
Performing judicious marking and paying attention to
the well-known dangerous zones is the most important
way to prevent any damage. By taking care regarding
the depth of the stitches, it is almost impossible to
injure a branch of the facial nerve.
The quality of the result will depend on the good
choice of traction points. The more lax the patient’s
skin is, the more traction will be needed. The final
loop, after tied, will tend to resemble the shape of a
circle. Sometimes it may be necessary to perform a
second plication (double stitch), and even a third one,
mostly in cases when the patient has suffered massive
weight loss. The second suture will overlap the first.
In patients with a specific point of laxity, it may
be necessary to perform additional braces to correct
certain folds and undertractioned areas. By using a
blunt Hagerdon Bayonet Modified Needle, it is
possible to achieve a desired point for pulling the
insufficiently treated area, performing a maneuver
described as “fish and tie”: the needle is passed and a
thread is pulled, fixing the desired area in the parotid
fascia. Another helpful maneuver is fixing the pla-
tysma to the fascia of Loré [17], therefore acting as a
cervical brace. It is recommended that all additional
braces be placed before the Roundblock stitch, hence
allowing free adaptation of tissues according to
facial expressions.
Pitfalls
Care must be taken with the distance from the ear to
prevent a “strangulation” of the auricular pavilion that
will promote pain and distortion.
Avoiding placement of the stitch beneath the SMAS
surrounding the parotid gland is a safe way to perform the
surgery. Deeper than this, stitches may be dangerous.
There is a low possibility regarding the occurrence
of hematomas. Although they may occur in a very lim-
ited area, they are mostly due to a high blood pressure
spike during the surgery or during recovery from total
anesthesia.
Suspension Techniques in Aesthetic Surgery of the Face
Acknowledgements To my sons Gustavo Flosi Stocchero and
Guilherme Flosi Stocchero, and to my son in law Alexandre Siqueira
Franco Fonseca, all of them physicians dedicated to Plastic Surgery,
who have always helped me with my papers.
References
1. Tonnard P, Verpaele A (2008) Reply to “Facelift with suspension
sutures”. Plast Reconstr Surg 121:677–680
2. Virenque M (1927) Traitement Chirurgicale des Rides de la Face et
du Cou. La Pratique Chirurgicale Illstrée, Paris
3. Mitz V, Peyronie M (1976) The superficial musculo-aponeurotic sys-
tem (SMAS) in the parotid and cheek area. Plast Reconstr Surg
58:80–88
4. Furnas DW (1989) The retaining ligaments of the cheek. Plast
Reconstr Surg 83:11–16
5. Stocchero IN (2001) The RoundBlock SMAS treatment. Plast
Reconstr Surg 107:1921–1923
6. Stocchero IN (2007) Shortscar face-lift with the RoundBlock SMAS
treatment: a younger face for all. Aesth Plast Surg 31(3):275–278
7. Stocchero IN, Fonseca AS, Stocchero GF, Stocchero GF (2006)
Lift facial com round block SMAS treatment. In: Stocchero IN,
887
Tournieux AAB (eds) Atualização em Cirurgia Plástica Estética e
Reconstrutiva. Santa Isabel Livraria e Editora, São Paulo, pp 73–77.
8. Duminy F, Hudson DA, Duminy F, Hudson DA (1997) The mini
rhytidectomy. Aesth Plast Surg 21:280–284
9. Saylan Z (1999) The S-lift: less is more. Aesthetic Surg J 19:406
10. Tonnard P, Verpaele A (2002) Minimal access cranial suspension
lift: a modified S-lift. Plast Reconstr Surg 109:2074
11. Isse N (2007) SAFE Lift. Presented at the III International
Symposium of Plastic Surgery, Buenos Aires, 17 Aug 2007
12. Zimman O (2007) SMAS Suspension. Presented at the III
International Symposium of Plastic Surgery, Buenos Aires, 17 Aug
2007
13. Marchac D (2008) Against the visible scar. Aesthetic Surg
J 28(2):200–208
14. Marchac D, Nask MN (2008) Avoiding the operated on look in
multiple face lifts. J Plast Reconstr Aesthet Surg 61:1449–1458
15. Marchac D (2009) Évaluation de 50 liftings cervicofaciaux monob-
loc avec suspension. Ann Chir Plast Esthet 54:103–111
16. Van der Lei B, Cromheecke M, Hofer SOP (2009) The purse-string
reinforced smasectomy short scar facelift. Aesthet Surg 29:
180–188
17. Labbé D, Franco RG, Nicolas J (2006) Platysma suspension and
platysmaplasty during neck lift: anatomical study and analysis of
30 cases. Plast Reconstr Surg 117:2001–7
 Rejuvenation of the Midface
Brunno Ristow
1 Introduction
The rejuvenation of the midface continues to fascinate sur-
geons dedicated to restoring natural and youthful contours
be they novices or experts.
What follows are my current concepts and techniques
based on significant amount of years dedicated to obtaining
these results. Approaches I use benefited from ideas
expressed by colleagues; however, personally, I trace the
beginning of a major departure from the accepted standards –
and a cornerstone beginning it was – to Tord Skoog [1]. His
suspension of the fascia above the fat pocket of Bichat set me
on a journey which is one of the pillars of what I came to use
[2–4]. Not the only important one, but a cardinal concept.
Much followed with the identification of the superficial
musculo-aponeurotic system (SMAS) and its history making
victory in the midface. Although for a decade I continued my
evolution, Skoog’s suspension remained constant. In the fol-
lowing decade, I was influenced by Connell [5], and finally,
I evolved into a synergistic link of these concepts [6–8].
Further refinements came with the transfers of untrauma-
tized segments of SMAS or fat to deficient areas of the face.
Today, Skoog’s and Connell’s ideas are still transparent in
the results, and I am certain to say, fundamental keystones to
the anatomical framework that supports noteworthy results
[3, 6].
I found myself working mostly alone in my professional
career. This partially offered me the opportunity to study the
problems and try to develop solutions. Of the two basic
methods of progress, the first being experimentation that
leads ultimately to conclusions sometimes unknown or the
second having intuition of an outcome and applying that
thought to the anatomy, personally I fit on the last group.
B. Ristow, MD, FACS
Private Practice, California Pacific Medical Center,
San Francisco, CA, USA
e-mail: brunnoristow@yahoo.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_63
Frequently, and for many years, I examine lovely faces and
think: “How can we (surgically) achieve this?”
It was and is still a game of chess to quote a reflection of
Jack Sheen; “A game between you and the anatomy … and
we have to win.” In this, there is great truth: in rejuvenating
the face, as in chess, not all moves are exactly predictable;
but knowing a good many of these surgical nuances, coupled
with reverence for the resilience or delicacy of tissues, will
make the surgeon the one that at the end, checkmates the
aging face.
2 General Considerations
In the midface, there are two consequential fascias. The first
is the superficial fascia, meticulously described as part of an
anatomical system known as the superficial musculo-
aponeurotic system (SMAS) [9]. This structure of substance
can be separated from the far more delicate second fascia,
the deep facial fascia (DFF). This deep fascia, in turn, covers
the parotid gland, the masseter, and lies over the motor
nerves, and is clearly discernible as a structure.
Advancing the SMAS and all its overlying structures (fat,
septa, skin, vessel networks) over the DFF and securing this
shift in a new position constitutes the essence of the modern
facial rejuvenation. Lovely, natural, long-lasting results that
please and delight patients are anchored on the ability and
skill of the surgeon to master these maneuvers.
3 Anatomical Issues
To surgeons, the understanding of the position of the fat in a
young face, its distribution and the consequence this has on
the surface contours of the face is essential. These are the
features that we need to restore. Only by knowledge of where
these structures are in the youthful face can we surgically
reposition them in their original location. This approach will
rejuvenate the patient without altering any of their features
889
890
that identify them as specific individual. That the skin over
the midface remains relatively static with aging but the fat
shifts has been elegantly demonstrated [10].
As we age, the fat atrophies and slides between the septa,
which connect the fascia to the skin, and leaves its original
location over the orbital rim and the malar eminence. In fact,
if one studies the contours of beautiful women in their 30s it
is not unusual to see a subtle concavity of the contours of the
midface below the height of the malar eminence. Very young
women in their teens usually have more overall facial fat.
(Veil of Mourning Girl, Getty Museum, Fig. 1 [11]) Their
faces are almost exactly like the contour of an egg held
upside down. With adulthood, this excessive fat seems to
absorb. With the passing of years, the fat will follow a gravi-
tational course downwards. It leaves the malar eminence,
exposes eyelid fat pockets and orbital rim, fills the subtle
submalar depression, and hangs in pockets of variable sizes
in the jowl region.
Those are the anatomical realities we face and plan to
reverse with our procedures. The SMAS and its utilization as
a tough and strong structure that we can advance and which
in turn will bring with it all the elements of superficial to it
(skin, fat and largely and impressively independent blood
supply) is an undeniable triumph of surgeons. Now we can
Fig. 1 Veil of Mourning Girl, Getty Museum
B. Ristow
achieve results that are natural, contours that the patient had
when younger, with no alteration of the fundamental param-
eters, which confer each person their unique appearance.
Operations that essentially base their result in dissecting
above the superficial fascia (SMAS) will destroy the septa
that connect it to the skin, severely compromise the blood
supply, and likely achieve a combination of short-lived artifi-
cial and unnatural results. Mentioning a “skin lift” in the
twenty-first century may seem out of touch with our develop-
ments. A question worth addressing is if there is a place for
procedures that disregard the SMAS; in my opinion, the
answer is no. I write this because poor results will tena-
ciously reflect on surgeons. Patients are not equipped to
understand the intricacies of beautifully executed procedures
(SMAS elevation) and poor ones, but will in general, cor-
rectly evaluate outcomes.
4 Selective Issues Included
in a Consultation
I believe that a general understanding by the patient of how
our faces age is important. The prospective candidate will be
reassured that with this approach she (or he) will not look
“different” but simply look like themselves years younger.
Also, showing pre- and postoperative photographs reassures
them that the surgeon is skillful and able to produce the
results anticipated. [On a rare occasion, a patient may criti-
cize a most excellent result and luckily, therefore, gives us
the opportunity to catch a glimpse of an unreasonable expec-
tation, and therefore, to reconsider our willingness to under-
take the surgical journey.]
More frequently, because of poorly performed previous
surgery, we encounter a frightened patient. She or he is typi-
cally well dressed, of ideal weight, and properly acces-
sorized, but unquestionably apprehensive, “It took me so
long to come to consult because some of my friends look
frightening to me.” Fear of surgery and specifically fear that
is well grounded on poor results observed by the patient is
not uncommon and must be addressed. Also, longevity of
results by showing follow-ups up to many years will further
reassure the patient that she has found a competent surgeon.
Issues of detectability of surgery are also of importance
and cannot be overstated. In order to preserve natural hair-
lines, be it in the temporal or in the occipital region, the sur-
gical approaches must be explained because, by meticulous
work, hairlines are preserved, and incisions are exceedingly
difficult to detect (Fig. 2); however, there will be a few days
following the operation when all sutures are “at the hairline”
before the new growth underneath generates hair, which will
conceal the scar. The patient needs to trust your technique.
Lastly, there are the issues of informed consent. Universal
issues, such as bleeding and infections, are largely influ-
Rejuvenation of the Midface
Fig. 2 Close-up photograph of results of incision at the temporal
hairline
enced by the patients themselves (ASA, compliance with
antibiotics, schedules prescribed, etc.), but going through at
least some of the most important possible complications
(e.g., infections, preoperative chemoprophylaxis of DVT
with alpha tocopherol [12], healing mechanisms, and nerve
injuries) is both advisable and helpful while conforming
with high standards. Since in experienced hands these occur-
rences are fortunately quite rare, it is also important that they
be placed in proper perspective.
5 Anesthesia
For decades, we have used a combination of light general anes-
thesia and a local anesthetic. The (all important) airway is prac-
tically always secured by laryngeal mask (LMA), and a
variation low concentration of sevoflurane, propofol, and remi-
fentanil is administered by a board-certified anesthesiologist.
(On the occasion of this writing, in developed countries, by and
large anesthesiologists consider this the standard of care).
Since we use various anesthesiologists, individual prefer-
ences apply, and techniques may vary among them; however,
891
one should remember that some anesthetics (e.g., isoflurane)
require 15 min of recuperation per hour of surgery. This may
not be ideal because a 4-h procedure would require 1 h of
recuperation, therefore, in general, we prefer quick-
elimination agents, be it gas, a narcotic, or a sedative.
Intraoperative and postoperatively long-acting drugs or non-
reversible drugs (e.g., Thorazine) are avoided.
At the conclusion of the procedure prior to the awakening
of the patient, I inject a solution of 1% Xilocaine (Novocaine)
with epinephrine as follows: the supraorbital and infraorbital
nerves, the mandibular branch of the trigeminal nerve and
superficial cervical plexus (both above and below the fascia
of the posterior border of the sternocleidomastoid muscle)
receive 1 cc of the solution per location. Another 0.5 cc of the
solution is placed in the scalp around the emergence of the
drain(s). This intersection of a short-term general anesthetic
with a long-term local anesthetic is undeniably important. In
the majority of patients, it reduces the necessity of postop-
erative narcotics to nearly zero; consequently, narcotic-
generated nausea is also rare [13].
Anesthesia drugs are in a constant flux of evolution. Their
inclusion here is to encourage surgeons to understand the
metabolic degradation time required for the elimination of
the various agents and to anticipate awakening lengths desir-
able for various procedures. Absence of discomfort and pain
together with a smooth emergence from anesthesia is essen-
tial to the patients undergoing aesthetic facial surgery.
6 Procedure
6.1 The Temporal Region
During the consultation, I examine the degree of laxity of the
skin in the temporal region; specifically at the skin junction
to the temporal hairline (also earlobe and occipital excesses
are annotated. The position of the lateral brow is taken into
consideration as well.) The result of this exam determines in
part, if a temporal lift is indicated. Clearly, the temporal lift
does some remarkable improvements, which are the
following:
• It reduces the length of the “at the hairline” incision in the
temporal hairline.
• It supports the lateral canthal structures by repositioning
them 2 or more millimeters upwards.
• It rejuvenates the upper and lower eyelid and the position
of the lateral eyebrow.
Once the decision to do a temporal lift is made, the opera-
tion proceeds as follows: by placing my hands in the temporal
region within the hairline, I try to ascertain at which location
my vector of pull will produce the desired and most effective
892 B. Ristow

results. The hair is combed and parted, and a 3.5- or 4-cm to prevent hernias of the temporalis muscle. (These hernias
incision with a modest cephalad convexity is outlined. become visible when the patient masticates.)
Utilizing a 27 ga in inch needle, local anesthesia with epi- A #10 French round silicone drain, fluted (Hemaduct JP
nephrine is specifically placed in the lateral orbital rim and Cardinal Health HUR-100), is inserted with the tip into the
into the SOOF (suborbicularis oculi fat). SOOF, exiting in the temporal scalp (Fig. 6), where it is
Incisions are made through the scalp only with a #10 secured with #3-0 Prolene. Later, after the midface is dis-
Personna Plus knife. The knife is beveled, as to preserve at sected, the drain is retrieved from the SOOF space by a
least one row of follicles underneath the cephalad margin of minute-sized spreading incision on the tissue overlying it
the incision. The caudad scalp is elevated for approximately and then placed under the SMAS. The advantages are mul-
1 cm from the underlying galea. The galea is now divided, tiple. The temporal fossa is drained, as is the sub-SMAS
leaving a 1 cm cuff on the cephalad portion of the incision region. The fluted drain, although next to the sentinel vein,
(Fig. 3). Initially with the Daniel elevator (Snoden-Pencer by not being a perforated drain, has never injured a vein upon
88–550) and subsequently with the Daniel soft tissue eleva- its (gentle) removal. With a Marten (Snoden-Pencer
tor (Snoden-Pencer 88–5058), the soft tissues are freed (sub- 88–2330) tension determining clamp (a variation of the orig-
galeal) from the temporal crest and the lateral orbital rim. inal D’Assumpcão), the complete temporal tissues are
The sentinel vein (rarely absent) is always preserved. It is advanced. Proper tension, as I have mentioned in previous
easy to identify this structure, and once this is done, the vein
is dissected free from its surrounding (quite strong) struc-
tures with the Potts tenotomy scissors, ideally configured for
this maneuver. The temporozygomatic nerve is not always
seen, but is left uninjured when present. A fiber-optic lit
retractor helps with complete direct visualization of these
structures and the dissection in the temporal fossa (Fig. 4).
Alternating visual appraisal of the progress of your dis-
section by looking from the outside and from the inside, plus
the guidance of the first assistant, I dissect into the upper
eyelid, free the external arm of the lateral canthal ligament,
and progress under the SOOF (Fig. 5) to below the zygo-
maticus major muscle. With the angled tip of a fine Colorado
needle, I make multiple (average 15) cuts of approximately
5 mm each in the fascia covering the temporalis. The intent
is to promote adhesions from the galea to the temporalis fas-
cia for a permanent and solid healing in its new upwards
position. Small cuts are preferred in opposition to larger ones
Fig. 4 Sentinel vein and tunnel under the SOOF clearly visible.
Temporal crest is released

Fig. 3 Cuff of galea cephalad portion of incision; silicone J.P. visible

below cuff. This cephalad cuff will be secured after proper elevation, to
the caudad galea (not visible, under the double hook) Fig. 5 The Daniel soft tissue elevator is in the SOOF
Rejuvenation of the Midface
Fig. 6 Shows the trocar under cephalad cuff of galea and through the
scalp
writings, “is a defining skill of our art.” Tension in flaps is
difficult to describe, but one “knows it” when we have gotten
to the maximum possible improvement without causing
adverse consequences.
A one, two, or occasionally three sutures of #3-0 Monocryl
are placed between the cephalad and the caudal galea, secur-
ing the appropriate elevation. (The use of a continuous suture
is contraindicated in the galea closure, since it can jeopardize
the blood supply to overlying hair follicles.) The small excess
of scalp is trimmed conservatively. The incision is closed with
#4-0 Prolene on a tapered needle. (A biodegradable suture
can also be used.) These needles allow precise placement of
the suture, always above the follicles. This technique pre-
serves intact the blood supply to the hair follicles.
6.2 The Midface
The drawing of the operation to be performed on the skin of
patients has always been a habit and it provides me with
invaluable help. Outlined in the skin are the extent of the
undermining of the subcutaneous layer and, in the sub-
SMAS region, the location of key elements, such as the
zygomaticus major muscle (ZMM), roof of the suctorial fat
pad of Bichat, crow’s feet lines, as well as the ideal point of
elevation of the SMAS first suture (Fig. 7). Next, the front
view of the patient’s photograph is scrutinized for which
side, right or left, should be operated first. The larger side is
operated first. By a complex mechanism that involves the
“hammock effect,” the side operated first will have slightly
more correction; not that this is clearly visible, but the oppo-
site, correcting the smaller side first will cause a visible dis-
crepancy. I recommend learning this early in one’s career
because I have not seen this paramount strategy mentioned in
the literature. It was pointed out that all of us have different
893
b
Fig. 7 (a) The drawings outlining the procedure. P.I.S. point of ideal
suspension, (b) root of fat pocket of Bichat, Dotted area Sub-SMAS
dissection, Arrow direction of SMAS towards fixation. (b) The 27
gauge needle, placed through the skin at the point of ideal suspension
shows (as in this photo) almost invariable through the SMAS just above
the lowest portion of the zigomaticus major muscle
sides of the face [5]. Amplifying it to which side we operate
first, bears consequences on ultimate results.
A short distance between the temporal hair and the eye-
brow is also indicative of youth and beauty; one is able to
advance the temporal hair perhaps 5 or more millimeters and
secure this location with deeply placed five zeros Monocryl
sutures in key locations.
6.2.1 Incisions
In the anterior temporal region, the incisions should be in a
location that leaves strong follicles of hair underneath its
cephalic edge. Incisions in very soft and delicate anterior
hair will be visible thereafter and should be avoided. There is
some mobility of the scalp forward, and it will compensate
for the sacrifice of the delicate two or three rows of fine hairs
that are anterior to the beveled cut.
As far as the shape of the lower temporal incision, women
should have a round incision and men a square one. This is
894
important, as squaring the temporal hair of a female is unnat-
ural, as is rounding the sideburns of a male.
The incision in relation to the tragal crest: In general, I
prefer an incision that follows the tragal crest for women. If
the incision is placed in the retro-tragal region, the tragus
becomes deformed and retro-tragal incisions are not used. A
pre-tragal incision is also quite good, especially if a small Z
is used on the upper tragus and a meticulous following of the
lines and contours of the lower ear cartilage are used. Finesse
in the earlobe and facial skin junction [5] is routinely per-
formed and involves leaving the transitional skin between
the earlobe and the face. Because of the beard pattern, this is
of particular importance in men.
6.2.2 The Dissection
There is an easy and natural plane of dissection in the tempo-
ral region. Below the follicles, a gently scissor-spreading
action will keep the surgeon in a safe level. This progresses
the anterior line demarcated on the skin. The midface dissec-
tion is at the subcutaneous level as well, and it advances to
the same line. If a complete facelift (which includes the sub-
mental region as well as the neck) is being done, at this stage,
a gauze moistened in dilute iodine is placed in the region,
and the neck is now addressed; if not, the incision will stop
at or behind the earlobe.
The low SMAS (which evolves anteriorly into a high
SMAS) (Fig. 8). A Bonnie Blue line is now placed in the
lower border of the zygomatic arch or slightly higher, but not
above the midportion of the arch. An initial high SMAS in
this region is not used because when the dissection is com-
plete, the SMAS either had to be placed under the temporal
hair or trimmed and discarded in its superior edge. (One
exception to starting the dissection of the SMAS LOW in the
zigomatic arch is the patient that has been operated by the
Fig. 8 The McIndoe insulated forceps surrounds the zigomatic arch.
Note the low SMAS flap, already elevated from point A forwards, all
dissection is sub-SMAS
B. Ristow
same technique previously. The SMAS being “non-elastic,”
in this instance, will not overlap the temporal hair.)
The Bonnie Blue drawing descends in front of the preau-
ricular incision to the angle of the mandible and then (in case
the neck is also being done) in front of the edge of the ster-
nocleidomastoideus muscle for another 3 to 5 cm.
The SMAS is now elevated from the preparotid fascia up
to the level of the junction A on Fig. 7. From this strategic
and important skin mark, all dissection forward is sub
SMAS; explained in other words, it is between the superfi-
cial and the deep fascia of the face (Fig. 8). The deep fascia
is delicate and transparent (one sees nerves on occasion
coursing underneath), and is a definitive structure which is
clearly identifiable. The advancement of the dissection is by
specially designed scissors (Ristow, Stille 101-8173-18),
semi-open tips gently pushing forward, separating the SMAS
(upper flap) from the DFF below. At the proper distance in
the lateral temporal region, I concentrate on finding the edge
of the orbicularis oculi muscle and proceed above it. My first
assistant will announce to me that the dissection is closed to
the zygomaticus major muscle (ZMM). (The assistant is
guided by the skin drawing.) Once the ZMM is identified, the
dissection goes above it and for a short distance anterior to it,
but most importantly, follows the ZMM downwards toward
the area of the roof of the fat pocket of Bichat. Here, on occa-
sion, one sees motor nerves appearing to go upwards into the
flap. In reality, they are not doing so. Gently spreading the
tissues on the roof of these nerves will see them suddenly
drop and continue in their course forward close to the fat
pocket of Bichat. In this anterior region of the face, the DFF
is not well defined. The assistant will normally inform me
that the anterior line of direction (drawing on the skin of the
face) has been reached. Throughout this dissection, exclu-
sively bipolar Silverglide (Link Tec, SF 712, M15844-02)
electrocoagulation is used, but for one or two notable excep-
tions. The perforating branch of the facial artery should be
electrocoagulated by a monopolar current, although the
application must be cautious. (The current will travel down
the artery on its way to the patch usually placed on the thigh
and secure a more effective hemostasis. With bipolar for-
ceps, the electricity is transmitted between the arms of the
forceps, with the artery interposed.) Bipolar is less thorough,
monopolar being more effective in securing bleeding from a
significant vessel.
6.3 Fat Transfers
Now is the ideal time for SMAS or fat transfers. I obtain
most of my fat from the submental region, but a principal
donor site is a strip of SMAS as well (in case the neck is not
opened, SMAS is the only source used.) It is very effective.
In previous years, I had made some observations regarding
Rejuvenation of the Midface 895

contours of the midface. These were that the elevation of the major muscle, is now closed with a single suture of #5-0
SMAS either at the fat pocket of Bichat or just above the Monocryl. Joel Pessa, MD, observed the results obtained by
lowest portion of zygomaticus major muscle would create a this technique and eventually did the extraordinary anatomi-
remarkable repositioning of the facial fat pad over the malar cal work that confirmed the compartmentalization of the fat
eminence. Further suspension of the SMAS would enhance in this location of the midface [14].
the malar eminence even more, but this maneuver (upon
drapping the midface flap with proper tension) would still
leave the midface with a flatness what was not entirely cor- 6.4 SMAS Advancement
rected. Youthful persons (see sculpture [11] show that the fat
of the face, anterior to the malar eminence, is abundant, but The tip of the #10 French fluted drain is now retrieved from
we know will decrease and mercilessly atrophy with aging. the SOOF and introduced under the SMAS (Fig. 12).
The placement of intact, non-traumatized fragments of fat A double loop of 3–0 Prolene is used in the SMAS using
and or SMAS, preserved in Ringers lactate slosh, diced in the skin marking of the P.I.S. (point of ideal suspension),
fragments of 3–4 mm and placed in the lumen of a 4-mm
diameter cannula with a side opening, can easily be intro-
duced into this deficient space. Small amounts of untrauma-
tized tissue transfers, into a vascular bed, will almost
certainly acquire their own blood supply. In addition, they
carry remnants of blood vessels and certainly stem cells
(Figs. 9 and 10). Patients who had fat transfers done looked
significantly better than those who did not have this addition.
Although our knowledge of the behavior of live tissue trans-
fers, at the time of this writing already exists, it is limited;
intuitively this makes sense and aesthetically, results are
clearly observed (Fig. 11b).
Lines are drawn on the skin of the face, and cannulas are Fig. 10 Properly sized SMAS/fat grafts and syringe loaded with 2.5 cc
loaded (usually they take 2.5 cc of tissue) and introduced, saline ready to place contents of cannula into midface spaces
coursing above, but close to the periosteum and advanced to
the desired location. The tissue is deposited while gently
withdrawing the cannula (Fig. 11a, b). A Luer Lock syringe a
with 2.5 cc of saline pushes the tissue fragments delicately
into the desired location. Two such “passes” per side will
suffice. The small aperture, which allowed the introduction
to the cannula, just posterior to the edge of the zygomaticus

Fig. 9 Stille Stevens scissor cutting properly sized segments of SMAS Fig. 11 Cannula loaded with untraumatized segments of SMAS/fat
or fat. The 4 mm cannula with a side opening and the Luer Lock syringe into Ristow’s space [14], for midface volume increase (a). The effect on
are also visible the surface anatomy of the soft tissue augmentation (b)
896 B. Ristow

Another point of suspension of the SMAS is secured

to the suprauricular area with a three zero black nylon.
Although different vectors have been proposed and can
be used, the correct one reveals itself by showing the
best and most attractive result in the face (the
SMAS wants to go in the proper direction) (Figs. 15
and 16).
An additional SMAS suspension suture is placed
approximately 2 cm in front of this last one (Fig. 17).
Therefore, the advancement of the SMAS in the midface
is secured in three different places and, by overlapping
itself superiorly, creates a solid fascia to fascia healing.
In full face lifts, the additional SMAS laterally is fash-
ioned as a flap and redirected in the occipital region where,
Fig. 12 The round drain has been retrieved from underneath the SOOF,
passed anterior to the PIS suture and laid under the SMAS
with appropriate tension, it contours the neck and supports
the submandibular gland. In case a neck is not planned,
this strip is removed. Since SMAS/fat transfers are done
a best prior to the fixation of the SMAS flaps in their ulti-
mate position, the surgeons should measure the excessive
SMAS, remove it and place it into the fat compartments
prior to the final SMAS fixation. The contour effects of fat
transfers are remarkable (Fig. 18) and clearly visible if the
surgeon compares the treated side with the non-treated
side of the face.
Lastly, the continuity of the SMAS between the poste-
rior edge (next to the ear) and the anterior edge (midface)
is reconstituted with a continuous suture of three zeros
nylon.

Fig. 13 Three zero prolene (SMAS to SMAS) in position to be tied (a)

and tied (b)

(Fig. 7a, b) and advanced to the cut edge of the SMAS over
the malar eminence (Fig. 13a). Using a tapered needle is
emphasized due to the fact that they “push” tissue aside as
opposed to cutting (which would weaken) the anchor site Fig. 14 Translation to surface anatomy after point of ideal suspension
(Figs. 13b and 14a, b). (PIS) suture is in place
Rejuvenation of the Midface
b
Fig. 15 Retracting the SMAS edge (a) and selecting the “best” loca-
tion of the anchoring suture (b)
Fig. 16 First SMAS fixation suture in place
6.5 Closure
Two key point sutures are now decided upon, again utilizing
Marten’s (or Pintanguys’s) clamps. The first and most impor-
tant is in the supra-auricular region. Once the flap is cut, a
897
Fig. 17 Second suture (above the zigomatic arch) in place. The suture
frequently enhances further the result
Fig. 18 Scissors point to Ristow’s space and the malar eminence,
where fat and SMAS fragments transfers are aesthetically important
four zero Monocryl with an inverted knot is placed in this
consequential point.
The flap is now redrapped, its excess outlined and
removed by a 10 Persona Plus blade. At least one additional
internal suture of five zero Monocryl is placed to recreate the
natural pre-tragal anatomic depression.
Dressings are never applied. The rational for this approach
is multiple:
1. It provides with quick inspection of the status of the
patient’s flaps and in case of any unwanted blood
accumulation it can gently be massaged towards the
drain.
2. It provides great comfort to the patient as there are no
firm or bulky dressings on their face.
898
3. It eliminates or decreases swelling of the eyelids by
allowing an even distribution of any postoperative edema.
Ice compresses can be applied to the flaps diminished
metabolic requirements.
7 Prospectus
“Drowning in a Sea of Data and Thirsting for Knowledge”
was the title of a conference (2007) at Berkeley University
by Sydney Brenner (Nobel Prize Laureate in Physiology or
Medicine, 2002) [15]. We surgeons can identify with these
words because notwithstanding that plastic surgery literature
contains numerous articles on the rejuvenation of the face,
some results could possibly be better. Connell [16] pointed
out that too frequently the rejuvenation “does not lift the cor-
ners of the mouth” yet Skoog published an effective tech-
nique for this problem in 1974 [1]. The production of good
results (Fig. 19) has a significant positive economical and
a b
Fig. 19 (a) The above sequence shows an unoperated patient on the
left. (b) The middle photo shows same patient 4 years after a forehead
lift with hair lowering, face and neck lifts, upper and lower blepharo-
plasties, and peri-oral dembrasion were performed. (c) The photo on the
B. Ristow
social impact on the patients, their work and their lives,
something we have witnessed repeatedly.
There are multiple factors that contribute to a good result.
Many important ones, I sincerely believe, are mentioned above.
Studying the various techniques used by experienced sur-
geons is helpful. Also, a surgeon should not always be satis-
fied with his own results; he should strive to continue to
improve on them further. An earlier teacher will help, but all
talented surgeons, slowly and incrementally improve their
technique. We frequently find hard to change techniques that
feel comfortable to us. To quote Rainer Maria Rilke:
“Whoever you are. One evening take a step out of your home,
which you know so well. Enormous space is near…” [17].
For me (figuratively) today, the surgical procedure is differ-
ent, ever so slightly from what it was yesterday and from
what it will be tomorrow.
Surgery is an opportunity where we have to think indi-
vidually about volume, proportion, beauty, aging, etc., and
apply our skilled technical knowledge on how to possibly
make our results increasingly better.
right shows the effect of midface only, which included SMAS grafts to
Ristow’s space and upper and lower lip volume restorations (by strips
of SMAS) and repeat perioral dermabrasion
Rejuvenation of the Midface
Fig. 19 (continued)
c
References
1. Skoog T (1974) Plastic surgery. W.B. Saunders, Philadelphia/
London/Toronto, pp 301–330
2. Ristow B (1987) Mid face rejuvenation. Presentation. American
Society of Plastic Surgeons, Atlanta, Nov 1987
3. Ristow B (1987) The suspension of the anterior SMAS to the zigo-
matic arch. Film, annual meeting, American Society of Plastic
Surgeon, Atlanta
4. Ristow B (1991) Aesthetic plastic surgery of the upper face. A
Division of Grosvenor Press International. Surg Tech Intl. Century
Press (1):325–327
899
5. Connell BF (1987) Facial rejuvenation. The artistry of reconstruc-
tive surgery. In: Brent B (ed). The C.V. Mosby Company Saint
Louis, Washington DC, Toronto. p 365
6. Ristow B (2007) Milestones in the evolution of face-lift techniques.
In: Grotting J (ed) Reoperative aesthetic and reconstructive plastic
surgery, 2nd edn. Quality Medical Publishing Inc., St. Louis,
pp 219–256
7. Ristow B (1995) As above. 1st edn. p. 181–204
8. Ristow B (2000) A personal technique for facial rejuvenation.
Aesth Surg J 20:235
9. Mitz V, Peronie M (1980) The superficial musculo-aponeurotic sys-
tem (SMAS) in the parotid and cheek area. Plast Reconstr Surg
66:675
900
10. Lambros V (2007) Observations on periorbital and midface aging.
Ageing Plast Reconstr Surg 120:1367–1376
11. Veil head of mourning girl. The J. Paul Getty Museum Collection.
Helenistic Period (used with permission)
12. Ristow B (2009) Special topic: preoperative use of alpha tocopherol
does not increase the risk of hematoma in the face lift patient: a pre-
liminary report. Plast Reconstr Surg J 124(5):1696–1699
13. Catterall WA, Mackie K (2006) Goodman & Gilman’s: the pharma-
cological basis of therapeutics. In: Laurens A. Brunton, John S
Lazlo, Keith L. Parker (eds). McGraw-Hill, New York, Eleventh
edn. p 377
B. Ristow
14. Rohrich RJ, Pessa JE, Ristow B (2008) The youthful cheek and the
deep medial fat compartment. Plast Reconstr Surg J 21(6):2107–2112
15. Sydney Brenner MD (2007) Nobel Prize in Physiology or
Medicine, 2002; title of talk at Berkeley University, California. A
Mathematical Research Institute (MSRI) representative certifies
that he is the first speaker they ever had not to use Power Point, an
overhead projector, slides, a chalkboard or notes
16. Connell BF (2008) Retrospective of my career in aesthetic surgery.
American Society of Plastic Surgeons, San Diego
17. Crichton M (1960) Travels, 2nd edn. Alfred A. Knopt, New York,
p 353
 The Minimal Access Cranial Suspension
(MACS) Lift
Marco Mazzocchi and Nicolò Scuderi
The minimal access cranial suspension (MACS) lift is a
facial rejuvenation procedure used to correct the aging neck
and the lower and middle third of the face. This procedure is
performed with the patient under local anesthesia and
sedation.
The core principle of the technique is a pure antigravita-
tional facial rejuvenation achieved by acting on the deep
facial soft tissues and the skin in the same vertical direction.
A submental limited skin undermining is performed through
a preauricular and temporal prehairline incision. Two strong
purse-string sutures are anchored to the deep temporal fascia
above the zygomatic arch for correction of the neck, the
jowls, and the marionette grooves. A third suture also origi-
nates from the deep temporal fascia can be added. It provides
a strong correction of the nasolabial fold, an enhancement of
the malar region, a lifting of the midface, and a shortening of
the vertical height of the lower eyelid. The skin is redraped in
a pure vertical direction, and the excess skin is excised for
adaptation to the temporal incision. This chapter describes
both the simple and the MACS-lift (Fig. 1).
1 Introduction
Many surgical procedures for the corrections of facial ptosis
have been described over the last years. These techniques
range from the mere subcutaneous dissection with removal
of exceeding tissues to the techniques of suspension of the
muscle-aponeurosis complex or of the periosteal. The need
for less invasive procedures is more economical and requires
a shorter recovery period, leading to the continuous develop-
ment of new techniques.
M. Mazzocchi, MD, PhD
Dipartimento di Scienze Chirurgiche, Radiologiche ed
Odontostomatologiche, Università di Perugia, Perugia, Italy
N. Scuderi, MD (*)
Dipartimento di Chirurgia, Università di Roma “Sapienza”,
Rome, Italy
e-mail: nicscuderi@gmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_64
In 1999, Ansari e Saylan proposed a technique, called
S-Lift [1, 2]. This technique is based on the suspension of
ptosis facial tissues with a non-absorbable suture. Using a
pre-auricular incision going upward along the line of hair at
the retro auricular level, we lift the tissues in subcutaneous
up to the nasal-buccal furrow and at the lateral edge of the
platysma. We reposition the tissues through sutures attached
to the periosteum of the zygomatic bone and the cheeks. The
medium third of the face is corrected. Thanks to a reposition-
ing of the malar fat in vertical direction by putting in tension
the nasal-buccal furrows.
In 2002, Tonnard employed the concepts of this technique
minimizing as much as possible the scars, using a vertical
purse-string suture with absorbable or nonabsorbable stitch
anchored to the deep temporal fascia [3–7]. The suspension
is made in the cranial direction to obtain antigravitational
volume redistribution of the soft tissues of the face (Fig. 2).
This technique seems to be capable to improve the facial
aesthetics making it appear younger. Thanks to an elevation
of the ptosis tissues, a repositioning of the malar prominence
and a flattening of the nasal-buccal furrows. Results are per-
manent and there are less complications than in other tech-
niques [3–7].
2 Patient Selection
More and more women and man from all walks of life, all
ages and backgrounds are investigating in face-lifting. These
patients are often unwilling to undergo aggressive and poten-
tially risk procedures to achieve their goals. They desire a
freshening, not a total overhaul, but only subtle correction of
the obvious signs of aging. The older patients we see also
welcome less aggressive but still effective surgical rejuvena-
tive procedures.
The MACS-lift provides a powerful correction of sub-
mental and upper neck laxity, correction of blunted submen-
tal angle, restoration of a well-defined jawline by correction
of the jowls, restoration of the midfacial volume, and
901
902 M. Mazzocchi and N. Scuderi

a b

c d

Fig. 1 (a–d) Pre- and postoperative images of a 56-year-old patient who performed MACS-lift
The Minimal Access Cranial Suspension (MACS) Lift
Fig. 2 Vectors of the MACS-lift
correction of nasolabial folds. Patients presenting with one
or more of these signs of aging are good candidates for
MACS-lift procedure, either as a simple or an extended
technique.
The ideal patient for simple MACS-lift procedure with two
sutures is a 45- to 50-year-old one, whose primary complaint
is a moderate submental laxity with a blunted cervicomental
angle but without visible platysmal bands. Jowls, marionette
grooves, and nasolabial folds are developing, but these are
mainly disturbing when the patient bends forward. This is a
very frequent complaint in middle-aged women, who discover
these first signs of aging in the lower third of the face.
Deciding whether to limit the intervention to a simple
MACS-lift or to add the third suture, as in the extended
MACS-lift, may be somewhat difficult in the beginning for
surgeons new to this procedure. The main consideration to
make is whether the patients need a correction of the upper
half of the nasolabial fold and midface. The third suture sus-
pending the malar fat pad gives a powerful correction to
these features. It also enhances the volumetric restoration of
the midface and provides very strong support of the lower
eyelid skin. This means that the indication for the third suture
can be extended to patients with a flattened malar mound and
laxity of the lower eyelids. This is not only determined by
age, but also by the facial bone anatomy. A person with a
poorly developed malar eminence will be subject to earlier
midfacial aging than the one with strong malar relief.
In a younger patient, an extended MACS-lift will correct
the malar insufficiency and flattening of the lateral cheek. In
an older patient, it will also correct the nasolabial fold and
midfacial hollowing.
In classical teaching, smoking is considered an absolute con-
traindication for face-lift surgery. Because of the limited subcu-
taneous dissection and the absence of multiplanar dissection, we
considered smoking more of a relative contraindication.
903
3 Surgical Technique
Preoperatively incision lines are marked, and the undermin-
ing area is bounded.
The marking starts at the lower limit of the lobulus, con-
tinuing up into the preauricular crease. The incision is usu-
ally carried out on top of the tragus. In the MACS-lift
technique, there is absolutely no horizontal pull, so there is
no risk of distorting the shape of the tragus. In a man with a
very posterior sideburn implantation, one can decide to carry
the incision in front of the tragus to prevent tragal hair
growth.
At the level of the incisura intertragica, the marking
makes a 90-degree turn backward to preserve the integrity of
this anatomic landmark. We then continue marking along the
posterior edge of the tragus, ascending toward the helical
root. There is a distinct color difference between the cheek
skin and the auricular skin. It is essential that the marking
follow this demarcation line precisely. At the superior limit
of the ear, the marking follows the small, hairless recess
between the sideburn and the auricle, then turns downward
to follow the inferior implantation of the sideburn.
In men, the marking descends approximately 1.5 cm
before turning anteriorly to cross the sideburn. The further
course of the horizontal marking runs forward the lower and
anterior implantation of the sideburn.
In this area, the marking can be performed in a zigzag pat-
tern to increase the length of the temporal incision for better
congruence with the length of the cheek flap. This will
decrease the tendency to develop dog-ears in this area. In the
simple MACS-lift, the incision will extend to the level of the
lateral canthus (Fig. 3). In an extended MACS-lift, the inci-
sion goes up to the level of the tail of the eyebrow (Fig. 4).
The total length of the incision will not exceed 7–9 cm.
The mandibular angle is marked as the lowest point of the
undermining; if an extended MACS-lift is planned, the malar
eminence is marked. 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 5–6 cm in front of the ear.
The marking is the direct toward the upper end of the inci-
sion, incorporating the preoperative marking of the malar emi-
nence in the case of an extended MACS-lift (Figs. 3 and 4).
When an extended MACS-lift is planned, the position of
the third suture has to be marked preoperatively. A point is
marked 2 cm caudal to the lateral canthus. In most of the
people, this point coincides with the bulk of the malar fat
pad. The effect of this suture can be simulated by pushing
this surface point in the same direction, revealing the effect
on the nasolabial fold, nasojugal groove, and lower eyelid.
The surgery can be performed under local anesthesia and
sedation or under general anesthesia having into account the
state of health of the patients. In both cases it is necessary,
904
Fig. 3 Image of the incision (in red) and of the undermining in the
MACS-lift
Fig. 4 Image of the incision (in red) and of the undermining in the
extended MACS-lift
however, to perform an infiltration of the treated area. We
usually use an anesthetic solution consisting of saline with
lidocaine, naropine, and epinephrine 1:250,000. This is infil-
trated in the subcutaneous tissue of the treatment area taking
M. Mazzocchi and N. Scuderi
into account the preoperative design. Approximately,
40–60 ml of anesthetic solution is injected for each side.
The incision is started at the lobulus and continued along
the previously described markings. Care is taken to respect
the incisura intertragica by making a distinct 90-degree turn
at the beginning of the tragus. The hairline along the hairless
recess at the upper end of the helix is followed toward the
sideburn. The blade is then inclined to an angle of 30° to the
skin so that the incision goes obliquely through the dermis,
perpendicular to the hair shafts. The oblique incision within
the hairline will cause hair to grow through the scar. If neces-
sary, in this area, the incision can be performed in a zigzag
pattern to increase the length of the temporal incision for
better congruence with the length of the cheek flap and
decrease the tendency to develop dog-ears.
After the incision has been completed, the flap is dis-
sected in a subcutaneous plane. Special care is taken not to
injure the tragal fibrocartilage. Usually the first centimeter of
the cheek flap is dissected with the knife, the rest of the
undermining is done blindly with Rees face-lift scissors. The
dissection is performed in a subcutaneous plane. Care is
taken to create a flap of sufficient thickness to mask small
irregularities of the underlying layer. After creating the flap,
hemostasis is ensured.
In the simple MACS-lift, a limited skin flap is under-
mined in an oval area extending from 1 cm above the zygo-
matic arch to the mandibular angle caudally and about 5 cm
in the anterior direction (Fig. 3). In the extended MACS-lift,
the subcutaneous undermining is extended over the area of
the malar fat pad (Fig. 4).
Undermining shall not extend too inferiorly and medially
in the cheek, so that the sutures do not extend too much medi-
ally where they could trap the branches of the facial nerve.
The first 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. A 0.5 cm diameter window
is made in the subcutaneous tissue to visualize the deep tem-
poral fascia, which should be identified, avoiding to trauma-
tize the superficial temporal vessels (Fig. 5).
The first bite is taken deep down to the temporal bone (to
be sure that the deep temporal fascia is included) in a cranio-
caudal direction. The needle usually exits at the pretragal
area. The purse-string suture is continued in a narrow U-shape,
first in a craniocaudal direction, descending in front of the ear
from the first bite down to the mandibular angle, making a
U-turn, and returning 1 cm anteriorly in a parallel cranial
direction to the starting point. A firm amount of parotid fascia
in the cranial part and of platysma in the caudal part is taken
with every bite of the needle. The purse-string suture is then
tied under maximum tension, exerting vertical traction on the
platysma, which causes strong elevation of the whole anterior
neck region. The knot is buried in the soft tissue to prevent it
from being visible or palpable through the skin.
The Minimal Access Cranial Suspension (MACS) Lift
Fig. 5 Location of the sutures in the MACS-lift
The second suture originates from the same location on
the deep temporal fascia (Fig. 5). This purse-string suture
forms a wider loop directed toward the jowls, at an angle
of ± 30° with the vertical. This loop is more O-shaped than
U-shaped vertical loop. Especially in patients with a fatty
face, care must be taken to take parotid fascia and the super-
ficial musculoaponeurotic system (SMAS) in the bit. The
anterior part of the loop goes no further then 5–6 cm preau-
ricularly. After tying this suture under maximum tension, a
very effective elevation of the jowls is seen. At this moment,
some dimpling will be seen at the limits of the undermined
skin, which is corrected by freeing the retracted skin with
scissors. In some cases, bulging of the SMAS tissue can
occur in the center of the oblique purse-string loop, espe-
cially in fatty faces. To prevent this bulge’s being visible
through the skin, the upper part of the bulge is sutured supe-
riorly to the subcutaneous tissue. If necessary, the lower part
of the bulge can be trimmed with the scissors.
When an extended MACS-lift is performed, the third
suture is necessary. This has a separate anchor point on the
deep temporal fascia, just lateral to the lateral orbital rim
(Fig. 6). This suture forms a narrow U-shaped loop to pre-
vent bulging of subcutaneous tissue in the highlighted zygo-
matic area. It runs to the malar fat pad, which has been
preoperatively located by a point marked 2 cm below the
lateral canthus.
By spreading the scissors, a window is made in the orbi-
cularis muscle just lateral to the lateral orbital rim, and the
deep temporal fascia is exposed. A deep bite is taken, anchor-
905
Fig. 6 Location of the sutures in the extended MACS-lift
ing the suture to the deep temporal fascia. The purse-string
suture is oriented obliquely downward and medially. The
malar fat pad is recognizable by a more fibrous consistency
than the surrounding subcutaneous fat. At the preoperatively
marked point referring to the malar fat pad, the direction of
suturing is reversed, now in an upward and lateral direction.
The suture ends at its starting point in the window made in
the orbicularis muscle. The knot is tied under maximal ten-
sion. The window in the orbicularis muscle is closed with
4-0 Vicryl to prevent knot palpability in the lateral orbital
region. Again, some skin dimples may have to be freed with
the scissors at the borders of the malar undermining.
When the suture is put under traction, not much move-
ment is seen in the midface. With the patient lying down, the
midface is already flattened out and shifted upward; so to
confirm the effectiveness of the malar loop, we simulate the
standing position by pulling downward on the malar region
with the fingertips.
An obvious skin excess will appear in the lower eyelid,
which will be taken care at the end of the procedure with a
lower pinch blepharoplasty.
After performing the purse-string sutures, the skin
redraping and resection are performed. Because the vector
of the subcutaneous lifting is almost purely vertical, redrap-
ing and resectioning of the skin in the same direction will
seal the underlying suspension effect. The skin flap is put
under moderate vertical tension and the skin excess is
excised (Fig. 7). Just before closure, meticulous hemostasis
is confirmed.
906
Fig. 7 Both in classic and extended MACS-lift, the skin is removed by
applying a vertical traction to the skin flap
The skin is sutured under strong vertical tension with sub-
cutaneous sutures of 4-0 Vicryl. There is no traction in the
horizontal direction. The preauricular incision is sutured
under minimal tension. The earlobe, which is pulled crani-
ally by putting vertical tension on the skin flap, is simply set
back without tension as a little transposition flap. This avoids
the risk of creating an unnatural, pulled-down earlobe [8].
A small Penrose drain, or suction drain, is inserted in the
lowest part of the incision at the earlobe, and a further clo-
sure of the skin is performed with 5-0 Vicryl subcutaneously
and with 5-0 and 6-0 Nylon continuous and interrupted skin
sutures. Ice cooling is applied for 2 h after the procedure, and
a light compressive dressing is left on for 1 day. The dressing
and drain are removed the next day, while all sutures are
removed at day 7. Patients have to intake oral antibiotics and
pain medication. All patients are offered the opportunity of
having daily facial lymphatic drainage massage during 1
week, starting on postoperative day 3–4.
4 Results
The MACS-lift allows the lifting of the jaw area and the mid-
dle third of the face. Jowling, marionette grooves, and the
nasolabial folds are well corrected and the vertical height of
the lower eyelid is diminished resulting in a better transition
from lower eyelid skin to cheek skin. The results reveal a
good correction of facial volumes in an upward direction.
M. Mazzocchi and N. Scuderi
In all the patients of our series, we observed an improve-
ment in facial aesthetics making their skin appear younger
(Figs. 8 and 9)
Most of the patients were able to resume normal activities
and normal social life after about 2–3 weeks after surgery.
We observed minimal complications.
We observed persistent edema for more than 2 months
(20 %), ecchymosis (18 %), dysesthesia (10 %), hematoma
(6 %), defects of scarring (2 %), infection (2 %), palpability
of the knot of the sutures (1 %), particularly in the third
suture, and suffering of the apices of the skin flap (0.5 %). In
our series, we did not observe any case of severe hematoma,
severe seroma, skin necrosis, and skin thinning or skin depig-
mentation. During the follow-up, we did not observe any
recurrence of the tissues laxity. This shows that the purse-
string suture remained intact.
In all patients of our series, the desired correction of the
aging facial features was obtained and remained stable for
the extent of our follow-up (60 months).
5 Discussion
Facial aging is caused by a multitude of factors: the years of
gravitational pull on the soft tissues between the skin and
the facial skeleton, loss of elasticity of the skin caused by
intrinsic and extrinsic factors, possible facial deflation
caused by fat atrophy, or even bone resorption [9–12]. These
different possibilities explain the multitude of therapeutic
approaches to counter the signs of aging [13–21]. One can
rejuvenate the skin by using resurfacing techniques, lifting
the sagged soft tissues, augmenting deflated areas with
autologous or other materials, or combining different proce-
dures. The MACS-lift is fundamentally a pure antigravita-
tional lifting procedure that will suspend the sagging soft
tissues of the face and neck, together with the adhering skin,
in a vertical direction into the place where they previously
belonged.
Therefore, any technique that works in a caudocranial
vertical direction will have a visual antiaging effect, whether
it is a lateral removal of the superficial musculoaponeurotic
system (SMAS) [16], a cranial suspension with purse-string
sutures, [1], a subperiosteal open [13] or endoscopic
approach [20], or a deep-plane face-lift technique [20].
Most classical face-lifts act on the level of the subcutane-
ous or superficial musculoaponeurotic system (SMAS) with
an oblique cranioposterior vector. The skin redraping usually
is performed in a more posterior vector, with care taken not
to raise the temporal hairline too much [8, 16, 22]. Any
oblique vector can be divided into a horizontal and a vertical
component. It is our opinion that the horizontal vector pro-
duces only flattening on the face, whereas the vertical vector
is the rejuvenating one.
The Minimal Access Cranial Suspension (MACS) Lift 907

a b

c d

Fig. 8 (a–d) Pre- and postoperative images of a 64-year-old patient who performed MACS-lift
908 M. Mazzocchi and N. Scuderi

a b

c d

Fig. 9 (a–d) Pre- and postoperative images of a 54-year-old patient who performed extended MACS-lift
The Minimal Access Cranial Suspension (MACS) Lift
A pure vertical vector on the deep tissues and the skin
produces the same rejuvenating effect without flattening the
face.
In contrast to the most frequently proposed classic face-
lifts [14], which all have a strong lateral vector of displacing
soft tissues, the MACS-lift is pure vertical-vector face-lift. In
recent years, the tendency has been toward less invasive tech-
niques in facial rejuvenation surgery. We observed an evolu-
tion in face-lift techniques from extended classic dissections
toward minimal incision techniques and from a lateral pull to
more cranially directed displacement of the soft tissues [21].
These techniques demonstrated stable and natural results
with minimal postoperative morbidity [13, 21, 23, 24].
Subperiosteal procedures can produce dramatic changes
with beautiful long-term results, but patients sometimes have
swelling that remains for 6 months [13, 17, 18]. Also, by
raising the periosteum, tissue is moved to a position where it
has never been. Indeed, the periosteum is the only anatomic
structure that stays fixed to the bone over an entire life.
With the MACS procedure, the sagging soft tissues are
brought back to their original position with a simple suturing
technique placed directly in the ptotic tissue.
For this reason, the postoperative recovery of the patients
is very fast and, as revealed by our experience, the postopera-
tive edema is reduced to few weeks.
In the simple MACS-lift, two purse-string sutures are
used to correct the lower third of the face. In the extended
MACS-lift, a third suture is added to correct the ptosis of the
middle third of the face. This suture has an effect on the
nasolabial fold, the malar fat pad, the junction between the
lower eyelid and cheek, and reduces the vertical height of the
lower eyelid.
Most of the skin resection in a classic face-lift design is
done in the occipital region, producing the classic problems
of hairline displacement or noticeable pretrichial scars, a
problem that was never encountered in our patient group.
The horizontal limb of the MACS-lift incision enables us to
excise a large amount of facial skin in a vertical direction
without elevation of the hairline [25–27].
The advantages of a MACS-lift compared with classical
lifting techniques are a quick procedure, local anesthesia, no
hospital admission, a short recovery period, and an incon-
spicuous, short scar without rising of the temporal or occipi-
tal hairline. Perhaps most importantly, it is a safe procedure.
Facial nerve injury is unlikely to occur, and postoperative
numbness is significantly reduced [2, 28, 29].
Conclusions
The basic principle of the MACS-lift is to reposition the
soft tissues of the face through a suture which passes into
the SMAS and is anchored to the deep temporal fascia.
This produces an effective traction with a stable eleva-
tion of the SMAS that is transmitted to the soft tissues of
909
the face such as the cheeks, the malar fat pad, or nasola-
bial furrows. The skin resection is performed mainly in
the temporal area after vertical traction and repositioning.
Both classical and extended MACS-lifts are face-lift tech-
niques with vertical vector acting in antigravitational
sense. Both procedures are able to produce very satisfac-
tory results for the surgeon and for the patient.
Our experience confirms that this technique is a good
alternative to other rejuvenation methods of the medium
and lower third of the face. Moreover, this technique does
not excessively modify facial characteristics and does not
generate typical marks resulting from other procedures.
We also believe that the ideal procedure for facial reju-
venation is a procedure with a visible but natural change,
with minimal risk, with low morbidity and minimal social
discomfort and, in our opinion, the MACS-lift meets all
these requirements.
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tions: an approach to midface rejuvenation. Clin Plast Surg
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midface lift with minimal skin and superficial musculoaponeurotic
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 The Suprazygomatic (High SMAS)
Facelift
Bryant A. Toth
The superficial musculoaponeurotic system (SMAS) has long
been employed as the foundation for facial rejuvenation pro-
cedures. While a SMAS dissection has traditionally been
confined to below the zygomatic arch, we believe that this
does not adequately address changes associated with midfa-
cial aging. Undertaking a SMAS dissection superior to the
zygomatic arch allows for a higher arc of rotation of the mid-
face resulting in a more successful midfacial rejuvenation.
This chapter describes a high SMAS approach to facial reju-
venation in which the SMAS is elevated vertically and fixed
to the deep temporal fascia. A discussion of the relevant anat-
omy of the frontal branch of the facial nerve is presented.
1 Introduction
Since its original description by Mitz and Peyronie in 1974
[1], the superficial musculoaponeurotic system (SMAS) has
been a cornerstone for successful facial rejuvenation proce-
dures. However, dissection was always performed at a level
inferior to the zygomatic arch. Suprazygomatic (high SMAS)
techniques described by Connell [2, 3], Barton [4, 5], and
Alpert [6] allow for a higher arc of rotation of the midface,
which potentially translates into greater midfacial rejuvena-
tion by lifting the malar fat pad vertically and softening the
nasolabial fold. Moreover, the high SMAS method with fixa-
tion to the deep temporal fascia allows for a secure tighten-
ing of the entire musculofascial envelope of both the face and
neck (Figs. 1 and 2). The high SMAS facelift has become our
procedure of choice for both primary and secondary facelift
patients. It has proven safe and effective and very popular
with patients, offering high quality, long-lasting results.
B.A. Toth, MD, FACS
Private Practice, Toth Plastic Surgery, San Francisco, CA, USA
Clinical Professor of Surgery, University of California,
San Francisco, CA, USA
e-mail: tothbryant@gmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_65
2 Patient Selection
It is important in cosmetic surgery and even more important
in facial aesthetic surgery that the surgeon has a thorough
understanding of the patient’s goals and expectations of the
surgical procedure. The surgeon must make sure that the pro-
cedure itself exceeds whatever the potential expectation the
patient may have. Preoperative assessment includes an eval-
uation of the patient’s anatomical deformity, their psycho-
logical motivations for surgery as well as confirming that the
patient has realistic expectations, and an understanding of
the time frame for healing.
Appropriate medical clearance is verified by a preopera-
tive examination from the patient’s medical doctor as well as
lab data per the American Society of Anaesthesiology guide-
lines which include an EKG and blood work for patients
aged over 50. We also obtain lab data that evaluates the
potential bleeding status (PT, PTT, platelets) of the patient,
and we recommend that the patient not take any medication
that impacts bleeding such as aspirin, excess vitamin C and
E, and herbal preparations. Smoking is an absolute contrain-
dication to this procedure and patients suspected of smoking
may result in cancellation of surgery or changing to a tech-
nique that necessitates minimal skin undermining. It is not
uncommon to refuse surgical intervention if the patient’s
goals are unrealistic or if the patient does not follow the pre-
operative plan. Preoperative photography consists of AP,
three quarter, and lateral views of the head and neck with
makeup removed and the patient not smiling.
3 Surgical Technique
All of our aesthetic surgery is performed in a private operat-
ing facility which is a part of the senior surgeon’s office
clinic. This arrangement allows the individual surgeon to
work with a surgical team of nurses and anesthesiologists
who routinely work together and understand the nuances of
911
912 B.A. Toth

a b

c d

Fig. 1 (a–d) Pre- and postoperative view 1 year of a 65-year-old woman following high SMAS facelift/necklift

facial aesthetic surgery. It avoids the changeover of staff for
breaks mandated by nurses’ unions in the hospital setting
and it avoids having equipment lost or misplaced that occurs
frequently in the main hospital operating room. We feel that
a team that works together often allows one to be able to take
their surgical results to a higher level.
Prior to surgery the patient is placed in an upright posi-
tion and normal anatomical landmarks are marked on the
patient’s skin. This includes the vector of ultimate pull of
the lift, the anatomy of the platysma and its bands, the limit
of dissection as well as structures to avoid such as the exter-
nal jugular vein. The patient is then induced with general
endotracheal anesthesia. The endotracheal tube is not fixed
to the skin and attention is made to avoid any type of trac-
tion on the tube. The table is then turned 180° with the anes-
thesiologist remaining at the foot of the bed and out of the
way of the surgeon. The face is prepped with chlorhexidene
with care taken not to contact the cornea. A solution com-
prised of normal saline with lidocaine and epinephrine
1:250,000 is then injected subcutaneously into the intended
surgical field. Approximately 75–100 cc of solution is infil-
trated on each side. One side is injected initially and the
injection of the second side is done at the time when the
patient’s head is turned to begin the opposite side. A stan-
dard periauricular, retrotragal incision is performed (Fig. 3).
A skin flap is then raised with sharp dissection. In the tem-
poral area, a two-plane technique is utilized to preserve the
superficial temporal vessels (Fig. 4). This also provides a
healthy blood supply to the temporal hair follicles. In gen-
eral, we dislike pretrichal incisions particularly in the
younger patient due to the scarring involved, and the inabil-
ity of the younger patient to pull their hair back without hav-
ing the tell tale scars of surgery. We will tolerate the lifting
of the sideburn to the level of the root of the helix. In a sec-
ondary procedure, an incision rotating down the hairline at
the pretrichal level is necessary.
The skin dissection is carried out over the parotid and
mandibular border extending down into the neck and to the
The Suprazygomatic (High SMAS) Facelift
High SMAS - post High SMAS-pre
Fig. 2 Split face diagram showing a high SMAS facelift pre- and post-
operatively. Note the high arc of rotation of a high SMAS and the verti-
cal nature of the pull
Fig. 3 Periauricular, retrotragal incisions done with incision parallel to
hair follicles in the temporal region and care not to injure the tragus
midline as necessary. The retroauricular incision is mini-
mized and calibrated depending on the amount of ptotic neck
skin needing to be removed. Dissection of the SMAS itself
begins at the upper border of the zygomatic arch (high
SMAS). The dissection continues to the corner of the lateral
canthus with division of the orbicularis oculi muscle, if
desired. The dissection is then continued out over the parotid
913
Fig. 4 Biplanar flap with preservation of the blood supply to temporal
hair. The frontal branch is safely protected in the soft tissue.
Fig. 5 Dissection carried out over the parotid and masseter muscle
medially and inferiorly to the platysma. Note buccal branches of the
facial nerve overlying the masseter
and masseter muscle medially and inferiorly beneath the
level of the platysma (Fig. 5). Branches of the facial nerve
are identified and preserved. The SMAS is then elevated
2–3 cm vertically and fixed to the deep temporal fascia using
a 3-0 Prolene suture (Fig. 6). In the neck, platysmal bands
are divided through the facelift incision without making a
separate incision whenever possible. In a minority of patients
with severe platysmal bands, a submental incision with mid-
line plication may be necessary. A youthful neck contour is
restored by splitting the SMAS-platysma flap and pulling the
inferior limb laterally with fixation to the mastoid fascia.
Once the SMAS has been secured, the skin is redraped natu-
rally in an oblique direction (Fig. 7). The skin is fixed above
and behind the ear first without tension, utilizing a 3-0
Prolene suture. We prefer Prolene in this instance since its
914
a b
Fig. 6 (a, b) SMAS elevation pre and post for a 2–3 cm vertical lift. The SMAS is then fixed to the deep temporal fascia with a 3-0 Prolene suture
Fig. 7 The skin is redraped in a natural, oblique direction and sutured
without tension or pull
blue color can be distinguished from the dark hair color. The
occipital skin is then trimmed and inset without tension, fol-
lowed by the temporal skin, also with 3-0 Prolene. The pre-
tragal skin is adjusted and inset in the retrotragal position
without tension, using 5-0 a fast-absorbing gut. Two #10
Jackson-Pratt drains are placed into the face sitting on top of
the SMAS, one on each side. In general, the face is not
wrapped, so any small collection of blood can be readily
visualized in the postoperative period. A slow emergence
from anesthesia is then undertaken in order to avoid spikes in
blood pressure which could result in hematoma.
Care should be taken in the postoperative period to avoid
nausea and vomiting which along with pain and anxiety can
cause hypertension resulting in bleeding and hematoma for-
mation. We do not overnight our patients in our surgical
facility. All patients undergoing a facelift spend the first
B.A. Toth
postoperative night with a specialized private duty nurse at a
hotel close to our private clinic. Prior to discharge from the
clinic, the patient must prove that they can walk the hallway
and are clear of mind. Overmedication in the postoperative
period can result in complications that can easily be avoided.
The patient is always seen by a member of our staff on the
first postoperative morning. In general, sutures are removed
on the 12th postoperative day.
4 Results
Follow-up of our first 159 high SMAS operations performed
over a 4-year period for both primary and secondary proce-
dures revealed predictably satisfactory outcomes. There
were three significant complications (1.9 %): a hematoma
requiring evacuation; a single residual platysmal band; and a
case of transient unilateral lower facial weakness (resolving
completely within 6 months). All patients were ultimately
satisfied. The high SMAS facelift gives a youthful midfacial
appearance due to tightening of the entire musculofascial
corset of the face, while minimizing tension on the facial
skin. One hundred forty-nine patients (94 %) in this series
underwent concomitant procedures, including upper and/or
lower eyelid blepharoplasty (143 patients, 90 %), brow lift
(108 patients, 68 %), and other breast/abdominal/body con-
touring procedures (33 patients, 21 %).
5 Discussion
Traditional facelift procedures result in a vector of pull that
is largely lateral in orientation. This vector does not always
address ptosis of the malar fat pad associated with midfacial
aging. The high SMAS facelift technique results in a harmo-
The Suprazygomatic (High SMAS) Facelift 915

nious and natural lift by allowing the surgeon to achieve a
vertical vector elevation of the deep fascial system while
allowing for oblique vector elevation of the skin envelope
(Figs. 8 and 9) preventing gather of skin folds at the lateral
canthus. The differentiating factor for the high SMAS face-
lift is dissection superior to the zygomatic arch. The SMAS
is undermined, pulled vertically, and fixed to the deep tem-
poral fascia rather than transecting and suturing the cut
superior edge of the SMAS at the inferior zygomatic arch.
Although this technique (high SMAS) creates a greater reju-
venation of the midface, it is not widely practiced for fear of
frontal branch injury. We feel that SMAS plication alone in
traditional facelifting techniques is not as effective an anti-
gravity procedure and does not yield the best long-lasting
result.
Differing opinions exist regarding relationships of the
frontal branch of the facial nerve to the fascial structures
within the temporal and zygomatic area [7–16]. The tempo-
roparietal fascia (or “superficial temporal fascia”) is a con-
tinuation of the SMAS superiorly and is contiguous with the

Fig. 8 High-SMAS diagram HIGH SMAS LIFT

demonstrating the advantages of
the high arc of rotation with a b
elevation of the malar fat pat and
softening of the nasolabial folds
(a) frontal view (b) oblique view

Fig. 9 Low SMAS or LOW SMAS LIFT

infrazygomatic facelift with a a b
lower arc of rotation and less pull
and impact on the midfacial
structures (a) frontal view (b)
oblique view
916
Fig. 10 Diagram showing the
facial nerve and its branches.
Note that at the level the frontal
branch courses over the a
periosteum of the zygoma and
deep to the level of the SMAS
Temporal branches
Zygomatic branches
Buccal branches
Marginal mandibular n.
frontalis and galea above the temporal crest, whereas the
deep temporal fascia overlying temporalis splits into superfi-
cial and deep layers which invest the zygomatic arch (the
split is just posterior to the supraorbital rim at the “temporal
line of fusion”). A previous study by Stuzin placed the fron-
tal branch within the temporoparietal fascia as it crosses the
zygomatic arch. For this reason, and because the SMAS is
thinner over the zygomatic arch, plastic surgeons have been
reluctant to perform a suprazygomatic SMAS dissection for
fear of injuring the nerve, unless employing hydrodissection
in this area. In our patients with division of the SMAS flap at
the superior border of the zygomatic arch, we would expect
to see frontalis muscle paralysis in 100 % of cases. A study
by Campiglio [10], however, describes the frontal branch
coursing in the same sub-SMAS anatomic plane both above
and below the zygomatic arch, and this is confirmed in the
neurosurgical literature by Salas [15] (Fig. 10). In the plastic
surgical literature, Argawal showed that the frontal branch
runs in the innominate fascia in 100 % of cases [25]. We
therefore feel confident that the SMAS can be safely dis-
sected above the zygomatic arch without injury to the frontal
branch.
B.A. Toth
Regarding the single occurrence of temporary unilat-
eral facial weakness, it is postulated that injury to the cer-
vical branch was incurred during division of the platysma.
This resulted in loss of the ability to depress the lower lip
on the affected side, an effect which resolved completely
within 6 months. Daane and Owsley [17] described a simi-
lar occurrence, differentiating cervical branch injury from
insult to the marginal mandibular nerve by the patient’s
ability to evert the lower lip, because of the functioning
mentalis muscle (as seen in our case). It can be logically
inferred that the transient lower facial palsy seen here
occurred independent of suprazygomatic SMAS
dissection.
While other authors describe techniques involving limited
or absent SMAS dissection or achieve midfacial elevation by
means of plication [17–21], it is our philosophy that exten-
sive undermining prior to fixation is essential for a good
long-term “antigravity” result. Further, in the patient who
has undergone previous facelifting surgery, we found that the
SMAS can be re-dissected and lifted in a suprazygomatic
fashion, safely and with a successful outcome. Previously,
midfacial, surgical rejuvenation techniques have remained
The Suprazygomatic (High SMAS) Facelift 917

elusive [22–24]. We feel that the high-SMAS approach pro- Table 1 Average volumes for lipofilling injections
vides the simplest and most effective method of addressing Average lipofilling injection
aging of the middle third of the face. Injection sites volumes (each side) (cc)
Cheeks 3.0–7.0
Malar area 3.0–7.0
Nasolabial fold 2.0–3.0
6 Lipofilling and the High SMAS
Temple 3.0–5.0
Upper orbit 2.0–3.0
We have all become aware that in addition to the effects of
Chin 1.0–3.0
gravity, age results in facial soft tissue atrophy both at the
Lip (upper and lower) 1.0–2.0
skin level as well as the subcutaneous fat level. Although
the high SMAS is helpful in lifting the malar structures
back to their youthful location, the volume of tissue is less
than what was previously present. This is evident when
photos of the patient are compared to photos taken at a
younger age.
For the past year, we have been adding fat to the face
simultaneously at the time of high SMAS facelift with sig-
nificantly improved results. It also appears that adding fat
under stretched skin may improve the overall “take” of the
transferred fat. Typical amounts of simultaneous lipofill-
ing at the time of facelift are as shown in Table 1 and
Fig. 11.
Fat is harvested generally from the abdomen using the
Coleman [26] technique through periumbilical incisions
(Fig. 12a). The fat is taken using syringe technique and then
centrifuged separating the fat from the supernatant fluid and
oil (Fig. 12b). This fat is then transferred to 1 cc syringes and
injected into the face using small lipofilling needles
(Fig. 12c). This is done prior to the beginning of the facelift.
Fat is saved for additional injection as necessary at the com-
pletion of the procedure.
Prior to surgery, careful photography is done both with
and without a flash in AP, lateral, and oblique angles. The
photos taken without the flash are the most helpful in visu-
alizing volume loss and locations for adding fat. Note in
Figs. 13 and 14 the differences visualized in the face in
photos taken seconds apart, one with a flash and one
without. Fig. 11 Amounts of fat injected

a b c

Fig. 12 (a) Harvesting of fat using syringe technique; (b) separation of fat from supernatant fluid and oil; (c) transfer of fat to 1 cc syringes for
injection into the face
918 B.A. Toth

Fig. 13 Preoperative
photographs: (a) with flash;
a b
(b) without flash

Fig. 14 (a) A 62-year-old

female (AP view); (b) oblique a
view; (c) lateral view

b
The Suprazygomatic (High SMAS) Facelift
Fig. 14 (continued)
c
Conclusion
In summary, the suprazygomatic (high SMAS) facelift
allows a vertical vector of pull for the midface. The result
is restoration of a youthful midfacial appearance due to
tightening of the entire musculofascial corset of the face
and neck, while minimizing tension on the facial skin
associated with skin-only facelift procedures. This tech-
nique is a safe and effective method for restoring a youth-
ful facial appearance and at the same time producing high
quality, durable results for both primary and secondary
facial rejuvenations. The addition of lipofilling in the
same surgical setting as the high-SMAS technique now
allows both soft tissue atrophy and the effects of gravity
to be addressed.
References
1. Mitz V, Peyronie M (1976) The superficial musculo-aponeurotic
system (SMAS) in the parotid and cheek area. Plast Reconstr Surg
58:80–88
2. Connell BF, Marten TJ (1995) The trifurcated SMAS flap: three-
part segmentation of the conventional flap for improved results in
the midface, cheek and neck. Aesthet Plast Surg 19:415–420
3. Connell BF, Semlacher RA (1997) Contemporary facial rejuvena-
tion. Plast Reconstr Surg 100:1513–1523
4. Barton FE (2002) The “high SMAS” facelift technique. Aesthet
Surg J 22:481–486
5. Barton FE, Hunt J (2003) The high superficial musculo-aponeurotic
system technique in facial rejuvenation: and update. Plast Reconstr
Surg 112:1910–1917
6. Alpert B, Nahai FR (2004) Supra-zygomatic SMAS rhytidectomy
and the frontal branch of the facial nerve. In: American Society of
Aesthetic Surgery Meeting, Vancouver
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7. Abul-Hassan H, Von Drasel AG, Acland R (1986) Surgical anat-
omy and blood supply of the fascial layers of the temporal region.
Plast Reconstr Surg 77:17–24
8. Baker DC, Conley J (1979) Avoiding facial nerve injury in rhytid-
ectomy, anatomic variations and pitfalls. Plast Reconstr Surg
64:781–795
9. Bernstein L, Nelson RH (1984) Surgical anatomy of the extraparotid
distribution of the facial nerve. Arch Otolaryngol 110:177–183
10. Campiglio GI, Candiani P (1997) Anatomical study of the temporal
fascial layers and their relationships with the facial nerve. Aesthet
Plast Surg 21:69–74
11. Correia PC, Zani R (1973) Surgical anatomy of the facial nerve as
related to ancillary operations in rhytidoplasty. Plast Reconstr Surg
52:549–552
12. Furnas DW (1965) Landmarks for the truck and the temporofacial
division of the facial nerve. Br J Surg 52:694–696
13. Ishikawa Y (1990) An anatomical study of the distribution of the
temporal branch of the facial nerve. J Craniomaxillofac Surg
18:287–292
14. Pitanguy I, Ramos A (1996) The frontal branch of the facial nerve:
the importance of its variations in face lifting. Plast Reconstr Surg
38:352–356
15. Salas E, Ziyal IM, Beijjani GK, Sekhar LN (1998) Persistent
trigeminal artery: an anatomical study. Neurosurgery 43:
563–568
16. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA (1989) Anatomy
of the frontal branch of the facial nerve: the significance of the
temporal fat pad. Plast Reconstr Surg 83:265–271
17. Daane SP, Owsley JQ (2002) Incidence of cervical branch injury
with “marginal mandibular nerve pseudo-paralysis” in patients
undergoing face lift. Plast Reconstr Surg 111:2414–2418
18. Noone RB (2006) Suture suspension malarplasty with SMAS
plication and modified SMASectomy: a simplified approach to
midface lifting. Plast Reconstr Surg 117:792–803
19. Tellioglu AT, Hosaka Y (2006) Temporoparietal fascia plication in
rhytidectomy. Aesthet Plast Surg 30:175–180
20. Tonnard P, Verpaele A, Monstrey S, Van Landuyt K, Blondeel P,
Hamdi M, Matton G (2002) Minimal access cranial suspension lift:
a modified S-lift. Plast Reconstr Surg 109:2074–2086
920
21. Tonnard P, Verpaele A, Gaia S (2005) Optimizing results from min-
imal access cranial suspension lifting (MACS-lift). Aesthet Plast
Surg 29:213–220
22. Toth BA, Daane SP (2004) Subperiosteal midface lifting: a simpli-
fied approach. Ann Plast Surg 52(3):293–296
23. Heinrichs HL, Kaidi AA (1998) Subperiosteal face lift: a 200-case,
4-year review. Plast Reconstr Surg 102:843–855
24. Hester TR, Codner MA, McCord CD (1996) The “centrofacial”
approach for correction of facial aging using the transblepharo-
plasty subperiosteal cheek lift. Aesthet Surg J 16:51
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The course of the frontal branch of the facial nerve in relation to
fascial planes: an anatomic study. Plast Reconstr Surg 125(2):
532–537
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Autologous fat grafts harvested and refined by the Coleman
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932–937
 Surgical Treatment of Ageing
in the Neck
Mario Pelle Ceravolo
1 Neck Aesthetics
Regarding the aesthetics of the neck, the parameters that
constitute beauty are the following:
• A well-defined lower jaw and chin line
• A clear, horizontal or slightly convex line running from
the caudal border of the chin to the hyoid bone
• A cervico-mandibular angle between 105° and 120°
• A ratio greater or equal to ½ between the horizontal and
vertical segments of the neck
Obviously, we must apply a certain degree of elasticity to
these precise measurements and geometric criteria when
dealing with the human body. Indeed, the rigid geometrical
perfection of the male physique described by Vitruvius was
later demonstrated to be flawed by Leonardo who, through
his detailed anatomical studies, reached the conclusion that
rigid numerical criteria were inapplicable to the human body.
Aside from numbers, there are other reasons why the
above aesthetic norms in our field should be considered as
merely theoretical. We cannot expect that the results of a
60-year-old patient following anti-ageing surgery of the neck
can possibly respect all of these criteria, however perfect the
results may be. Therefore we can consider these parameters
as indications of the characteristics that the perfect neck
should have the closer we are to these criteria, the greater the
general aesthetics of the neck.
In dealing with this complex region, first we shall exam-
ine the surgical techniques applicable to the neck and later
we will discuss the jawline which can be considered as a
transition zone between the neck and the face.
M.P. Ceravolo, MD
Docente di Chirurgia Estetica Master Università di Padova,
Padova, Italy
e-mail: mario.pelleceravolo@libero.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_66
2 The Various Layers of the Neck
Following a didactic-anatomical methodological approach,
we will first examine the neck from the superficial to the
deeper structures and then discuss the appropriate surgical
techniques to be adopted for the various structures.
I. The skin
II. The subcutaneous adipose tissue
III. The superficial muscular layer (the platysma muscle)
IV. The deep adipose tissue
V. The submandibular gland
VI. The deep myo-fascial layer
3 The Skin
The aim of the preoperative examination is to identify the
typology of skin and particularly, the following issues:
• Its elasticity, which is in part genetically predetermined
and in part influenced by age and other exogenous factors
such as exposure to sun, smoking, etc.
• The relation between the container and the content, in
other words, the quantity of skin excess present in the
neck region.
• The relation between the skin and the platysma
Of these three issues, skin excess in the most important.
This can be easily assessed through careful visual examina-
tion of the interested area and by applying simple physical
manipulation: pulling the skin in the opposite direction of the
age vectors which are more vertical in the paramedian region
and slightly more oblique and posterior in the lateral regions
of the face.
Further assessment can be made by asking the patient to
contract the platysma in order to assess the characteristics of
the muscle and the extent of skin laxity.
921
922
Another manoeuvre which can help evaluate the skin/
muscle rapport is to rub the skin up and down by pressing
lightly with the hand on a contracted and relaxed platysma.
This allows us to assess the adherence between the two lay-
ers and the relation between skin and the muscle laxity which
is an important parameter in evaluating the most opportune
corrective technique to adopt. We believe that the presence
of skin excess, as an inexorable result of ageing, is the most
common reason why patients opt to undergo a face-lift.
We believe that this skin excess should be removed as
much as possible.
The extent or aggressiveness of the excision is still a
subject of great debate. Until the end of the 1990s, the
majority of surgeons agreed on the necessity to generously
remove excess skin. Later, the increasing popularity of
deep traction techniques gave rise to a much more conser-
vative approach to both the extent of skin undermining and
the quantity of skin to be removed; necessarily so as these
two techniques are closely related. After conducting numer-
ous trials on limited undermining with disappointing
results, today we adopt a more aggressive approach to this
respect. Our view is to carry out an abundant excision of
any skin excess whilst avoiding excessive traction of the
cutaneous borders to minimise eventual negative effects
from undue tension. In order to do this, the skin must be
appropriately undermined. This will avoid any irregularity
due to the fact that the skin, which remains adherent to the
deeper layers, is not able to remodel.
3.1 Skin Undermining
The first question when considering any type of face-lift sur-
gery is how far should we undermine the skin?
To reply to this question we have to evaluate several fac-
tors of the skin such as its elasticity, the quantity and location
of the excess, the platysma and the other deep structures of
the neck. Obviously, the variability of all of these elements
can give rise to an overly complex and inapplicable
algorithm.
Dividing the patients into three broad classes according to
specific anatomical characteristics may help in choosing the
most appropriate type of undermining to be adopted.
3.1.1 Patient Classification I
All patients in this class have the following characteristics:
• A limited degree of skin excess localised mainly in the
lateral areas of the neck
• A moderate degree of laxity in the paramedian areas but
with well-toned skin-muscular layers and good adherence
between the two structures
• Absence of fat deposits in the anterior region of the neck
M.P. Ceravolo
In patients with skin excess limited to the lateral neck
regions and with a good level of elasticity, the extent for the
undermining can be “limited”, in that the mere traction
applied on the cutaneous flap can treat a limited skin excess
in the lateral areas of the neck. Normally patients in this cat-
egory are between 38 and 45-year-old and whose skin has
not been damaged by exposure to sun or adversely affected
by heavy smoking. Sometimes the poor quality of the skin
and superficial damage can be attributed more to these two
causes than the natural ageing process. Often we find
65-year-old patients who are non-smokers with an optimal
level of elasticity and other 45-year-old patients who have
over-exposed their skin to the sun or to a continuous smoke
poisoning – smoke which progressively mortifies its vitality.
When such patients show a minimum excess of adipose tis-
sue in the anterior region of the neck accompanied by a tonic
and elastic cutis, a viable option can be to intervene with
conservative, non-aggressive liposuction in this area. In the
presence of abundant adipose tissue, we prefer to sculpt the
fat under direct vision. Patients with these characteristics, as
we will see later, belong to the 3rd class.
In this chapter we will examine primarily skin undermin-
ing but naturally, we will also have to consider a series of
further interventions on the deeper structures which will be
discussed in greater depth in later chapters (Fig. 1).
3.1.2 Patient Classification II
Patients belonging to this class show the following:
• Considerable skin excess in the lateral areas of the neck
• Moderate presence of skin excess in the submental region
• Lax adherence between the skin and muscle layers as the
excess cutis is greater than the muscular excess
• Absence of appreciable fat accumulations in the anterior
region of the neck
• Absence of platysmal bands or deep structure problems
which require specific treatment by undermining the ante-
rior neck region
This class comprises patients with the above characteris-
tics as well as patients, predominantly from the 3rd class,
who specifically request more conservative treatment.
Obviously, it is important to respect the patient’s needs, even
if following our opinions, we would tend to intervene differ-
ently. The extent of undermining not only determines the
potential surgical risks but also the duration of the recovery
period, swelling, ecchymosis and the interruption of social
activity. We must remember that a more conservative surgi-
cal intervention poses limits to the possible results and con-
sequently, to the level of satisfaction of the patient. Therefore,
when obliged to “limit” the intervention either following the
patient’s specific request or by applying good sense (heavy
smokers, vascular or haemorrhagic pathologies, etc.) the
Surgical Treatment of Ageing in the Neck
Fig. 1 The extent of undermining and the retroauricular incision. In
these patients, the area to be undermined is “limited”, extending anteri-
orly to approximately 3 cm from the labial commissure and inferiorly to
7–8 cm caudal to the tragus, as indicated by the broken lines in the
diagram. These measurements are indicative for the average patient.
Indeed, there are concrete differences in the dimensions of the faces of
women 1.55 and 1.85 m tall (5 ft 1 in. and 6 ft 1 in.). In many of these
patients, this conservative approach will avoid scars beyond the retroau-
ricular sulcus
patient must be informed of this and must also give his/her
written consent (Figs. 1 and 2).
3.1.3 Patient Classification III
Patients belonging to this class show the following:
• Abundant lateral and anterior cutaneous tissue
• Skin excess in the lower anterior region (above the
jugular)
• Visible platysmal “cords” or “bands”
• Presence of deep vertical and oblique wrinkles of the neck
• Significant fat deposits in the anterior region
• Visible inaesthetisms due to the deep neck structures
(infraplatysmal fat deposits, deep muscles, hyoid bone)
Most of our patients (from 50 to 60 %) belong to this class.
A possible psychological reason for this is that many people
in our country opt for face-lift surgery only when the signs of
ageing are dramatically evident and not before. Consequently,
more aggressive treatment is required in these cases to achieve
adequate results. Furthermore, not all patients understand that
923
Fig. 2 The extent for undermining. In 2nd class patients, the undermin-
ing should be large, reaching approximately 1.5 cm from the labial
commissure, just beyond the mandibular angle and 9–10 cm caudal to
the tragus, as indicated by the broken line. In cases of skin excess in the
neck region, we are obliged to extend the incision to the mastoid area.
We prefer to have an incision here rather than a long incision in the
temporal area as do other colleagues who may prefer to adopt vertical
traction to avoid retroauricular scars. Naturally, there can be exceptions
to this rule
aggressive treatment is required to rectify great defects with
higher risks and a longer postoperative recovery period. This
renders sometimes the management of such patients prob-
lematic as they must be informed exhaustively on the possible
outcomes and more importantly, the limits and complications
of undergoing more aggressive surgery.
The area to be undermined comprises the entire submen-
tal area. The two hemifaces will largely communicate anteri-
orly through a tunnel extending from the submentum to a
point 4–5 cm caudal to the hyoid bone. Depending on the
specific anatomo-clinical condition of the patient, individual
variations may be necessary. Conservative treatment can
produce adequate results and a high level of satisfaction in
1st class patients and sometimes in 2nd class patients. In
these cases an overly cautious approach is counterproduc-
tive, unless dictated by physiopathological or practical con-
ditions (e.g. specific patients’ needs) which may limit or
render inadvisable certain surgical procedures. It is evident
that extensive undermining may increase the risk of haema-
toma or injury to noble structures, but we believe that this is
a necessary price that the surgeon (and above all, the patient)
924
must pay to obtain a good level of results. Despite our pro-
pensity for extensive undermining, a criterion which is
always respected is the absolute prohibition of extending it
beyond the nasogenian fold and the lateromental sulcus in
the mandibular region to avoid damage to important blood
vessels which become superficial in this region. Lesions to
these vessels can jeopardise the distal vascularisation of the
flaps. The criteria for undermining can also be influenced by
clinical evaluation (elasticity of the cutis, age, smoke-
provoked damage, pre-existing scars, etc.) or practical condi-
tions (specific needs, expectations of the patient, etc.).
Obviously, the target area for undermining is quantified in
the preoperative phase with the patient in an orthostatic posi-
tion. As for almost all our operations with rare exceptions, it
is vital that the entire surgical procedure be programmed
before the patient reaches the operating theatre, leaving
minor technical details which may be unforeseeable to be
decided during the operation. Sometimes we might modify
the decision for undermining intraoperatively as it is not
always possible to assess precisely the skin properties of
some patients before the operation (Fig. 3).
Fig. 3 The extension of the undermining. In 3rd class patients, the area
to be undermined comprises the entire submental area. The two hemi-
faces will largely communicate anteriorly through a tunnel extending
from the submentum to a point 2–3 cm caudal to the hyoid bone as
indicated by the broken lines. In some specific cases, the lower bound-
ary may also extend to the jugular fossette. There exists a certain degree
of variability in defining the extent of the undermining and this may be
conditioned by the presence of inaesthetisms and the surgical technique
to be adopted
M.P. Ceravolo
3.2 A Didactic-Anatomical Explanation
The superficial muscular aponeurotic system (SMAS) is a
myo-aponeurotic-adipose sheath composed mainly of fibro-
adipose tissue in the midface but which turns into pure muscu-
lar tissue (platysma muscle) at the level of the mandibular
border. Due to this reason we may use the term facial SMAS
or neck SMAS, but for didactic purposes and to facilitate the
understanding of the various surgical techniques applied to the
SMAS, in this publication we will use the term SMAS when
referring to the facial region and platysma when referring to
the neck region even if this terminology may be debatable as
we are dealing with a single and continuous structure.
3.3 The Subcutaneous Adipose Tissue
There are two main adipose compartments in the neck: the
superficial compartment and the deep compartment which
will be discussed in depth in Sect. 5.
The superficial compartment is represented by the subcu-
taneous adipose tissue. In a normal face, the distribution of
adipose tissue in the neck is very typical. Fat is present in all
areas of the neck but normally a greater accumulation is
found in the anterior region which tends to thin out in the
lateral regions, only to increase again in the infraauricular
area; fat thickness reaches a minimum value over the sterno-
cleidomastoid aponeurosis. The deep adipose tissue of the
neck, however, is much less diffuse. It is mainly localised at
the midline with a maximum thickness in the area delimited
by the medial borders of the anterior bellies of the digastric
muscles. Deep fat is different from superficial fat; it is more
solid due to its lower water content and is better vascularised.
The two compartments are partially separated by the pla-
tysma with an anatomic variability, as platysma bundles
cross on the midline at different height in each patient.
Cardoso de Castro studied the levels of platysma decussation
(crossing) defining a high, a medium and a low decussation.
The quantity of adipose tissue in the neck determines the
technique to be adopted; this entails different choice of treat-
ment between a thin and a fat neck. In a neck with limited fat
deposits in the submental area an open lipectomy approach
will be chosen with an incision on the submental fold. We
disagree with placing the incision posterior to the fold to
avoid a depressed scar; in our opinion this complication is
more attributable to excessive defatting than to the position-
ing of the incision. When the incision is placed in the sulcus
then it is almost invisible.
The undermining exposes the superficial adipose tissue which
is then removed progressively but conservatively preserving an
adequate amount of buffer between the skin and the muscle.
In cases of high platysma decussation, it is important to
identify the whitish, fibrous lamina which delimitates the
Surgical Treatment of Ageing in the Neck
deep fat and proceed to perform a conservative superficial
lipectomy. Then the deep fat layer is treated if needed.
Once the lipectomy has been completed in the anterior
neck which contains the highest concentration of fat, we
remove progressively by sight the fat localised in the lateral
areas of the neck aiming to create a regular contour. Final
touches on the superficial adipose tissue are carried out on
completion of all surgical manoeuvres (division of the muscle,
removal of the deep adipose tissue if needed, plication, etc.).
For patients with significant adipose tissue in the neck,
we prefer to start with non-aggressive, closed liposuction
with a thin 2-mm cannula to decrease the fat excess in the
area preoperatively marked with the patient in an ortho-
static position. Closed liposuction should never be applied
to the deep adipose tissue. In such cases, we use a single
port cannula (avoiding using the three port Mercedes type)
so as not to avulse fat on the deep aspect of the skin flap.
Attention must be paid to avoid overzealous aspiration,
leaving the delicate tasks of sculpturing the tissue to direct
vision and forceps. The use of the cannula in these cases (as
a first step, followed by open lipectomy) can be useful and
can also save time.
It is not uncommon to see patients who present problems
related to an aggressive neck lipectomy that has been carried out.
This happens for the following reasons:
• Due to the infiltration of the local anaesthetic and the
intraoperative oedema, it is difficult to assess precisely
the contour of the submental region. This may push the
surgeon to remove fatty tissue too aggressively.
Fig. 4 The submental area. A 64-year-old patient subject treated with
conservative anterior lipectomy. It is especially important in patients
with a thin cutaneous layer to conserve an adequate superficial adipose
layer to decrease the risk of eventual irregularities caused by inadequate
925
• When we remove an important amount of fat from the
anterior neck region the skin of this area will have to
retract, and its contour has to change from a convex to a
straight line. The skin of this region, in many patients,
however, has a limited elastic capacity similarly to the
skin of the supraumbilical area.
• Despite complete skin undermining, lateral skin traction
has a weak remodelling effect in the submental region;
this is because the anterior region of the neck is very far
from the points of traction.
It is important to conserve a stratum of adipose tissue in
the submental area, particularly in patients who have a thin
cutis and significant excess skin in this area. In the case of an
obtuse cervico-mandibular angle, we prefer to perform deep
subplatysmal lipectomy (as we will see later), conserving an
adequate layer of superficial adipose tissue. In this way, we
can correct the convexity of the contour and still maintain a
supporting cushion for the cutis.
Therefore in presence of excess fat in the anterior neck
area we prefer a conservative lipectomy from the superficial
layers associated with a more aggressive fat removal in the
subplatysmal compartment. This approach will preserve an
adequate cushion between skin and muscle which acts as a
support structure or cutaneous “splint” which can prevent
wrinkling, especially in skin with limited elasticity. Therefore
conservative lipectomy is strongly advisable in patients with
thin skin or in the elderly (Fig. 4).
Limited defatting is sometimes required for other reasons,
such as to avoid a protuberant submandibular gland masked
retraction of the cutis. Two months later we still have a slight submental
convexity due to a thin superficial fat layer which acts as cushion and
will continue to provide support for the contour in time
926
by superficial fat become more visible. Another reason could
be massive skin excess of the anterior neck which is impos-
sible to treat through lateral skin traction. In these cases, a
conservative lipectomy is required to avoid the risk of an
“empty pouch” effect. In other cases (necks with massive fat
excess and/or mandibular retrusion) in which it is not possi-
ble or inadvisable to intervene on the hard tissues, an aggres-
sive lipectomy may be justified.
It should be noticed, however, that in this type of necks the
obtusity of the cervico-mental angle is often related to the pres-
ence of deep fat, more than superficial, that is to be removed to
obtain the desired results. A differential diagnosis is mandatory
in these cases to choose the appropriate treatment.
Precise preoperative diagnosis and the evaluation of dif-
ferent surgical options allows us to formulate the ideal treat-
ment options for differing typologies of patients and to
maximise the results treating the existing inaesthetism with-
out enhancing the visibility of some anatomical features
which were present, even if not visible preoperatively.
Sometimes a certain quantity of adipose tissue can be
moved to a different position and used to mask deformities,
such as a protuberant submandibular gland, or to lengthen
the horizontal segment.
In conclusion, maintaining an adequate stratum of fat in the
submental region is extremely important, especially in patients
with very thin or inelastic skin. When skin has the support of
an underlying cushion, it is able to remodel well and further-
more, can hide any minor irregularities. Liposuction in the
submental region still has an important role. A fatty neck can
be treated by superficial lipectomy, but to achieve precise
results, this must be followed by careful sculpting under direct
vision and adequate treatment of the deep compartments, par-
Fig. 5 Infraauricular and submandibular lipectomy. By sculpting the
adipose tissue in these two regions we can define the mandibular con-
tour better in the lateral and medial third, thus improving the general
aesthetics of the entire neck. Appropriate sculpting of adipose tissue
can also give greater emphasis to the horizontal and vertical neck seg-
M.P. Ceravolo
ticularly through deep fat modelling. The removal of even a
limited quantity of deep adipose tissue gives particularly visi-
ble results due to its location in a key region of the neck.
3.4 Infraauricular and Submandibular
Lipectomy
When examining the distribution of fat in the neck, we must
always take into consideration the infraauricular and sub-
mandibular regions.
Sculpting fat in these regions is a necessary surgical
manoeuvre to obtain an acceptable contour of the lateral area of
the neck. The risk of creating an “empty pouch” effect, com-
mon in an anterior lipectomy, is less frequent in this region.
This is because the remodelling effect of the skin traction is
more effective in this area due to its proximity to the source of
traction. We often find that patients who have undergone neck
lifting may have one or more of the following: poor contour of
the lateral neck area, ill-defined mandibular angle, excess adi-
pose tissue and irregularities of the submandibular contour.
From a technical viewpoint, lipectomy is a straightforward
technique in the anterior and lateral neck regions but undoubt-
edly more difficult in other regions such as the mandibular bor-
der or lateral submental areas. The complexity of this
manoeuvre is the cause of more frequent fat remnants in the
submandibular rather than in the anterior submental region.
In cases of considerable excess fat in the anterior neck we
might use fat aspirated from this area for grafting. When fat
is lacking in this area and we need some autologous filler, we
might resort to using fat from the infraauricular or some-
times the submandibular areas (Fig. 5).
ments. In patients with well-defined bone structure, a standard face-
lifting can give satisfactory results. Contrarily, in cases of important fat
accumulation or weak bone definition, we have to employ other
manoeuvres such as the rotation of adipose flaps to obtain a satisfactory
neck contour
Surgical Treatment of Ageing in the Neck
Regarding the timing of the eventual lipectomy, the sub-
mental area can be carried out in the initial phase of the oper-
ation and completed later. The area over the mandibular
angle must be treated after having applied traction and repo-
sitioned the SMAS-platysma flaps in order to avoid that any
lipectomised areas are moved by the SMAS traction to inap-
propriate locations.
If the undermining is conducted at a subdermal level, the
entire fat layer is left undisturbed and can be trimmed by
applying the usual techniques. If we opt for deep or juxtamus-
cular undermining then we will have to remove some of the fat
which remains adherent to the deep surface of the skin flap.
In performing secondary surgeries in which the natural
cleavage plane is ill-defined, undermining can be less precise
due to fibrosis and this may cause part of the adipose tissue
to remain adherent to the deep surface of the derma.
4 The Superficial Muscular Layer (the
Platysma Muscle)
The platysma muscle covers a particularly important role in
the ageing of the neck. Its treatment is based on four funda-
mental elements:
1. Undermining
2. Traction vectors
3. Section
4. Sutures
4.1 Undermining the Muscle
After skin undermining and treatment the superficial fat we
can proceed to deal with the most important structure of the
neck, the platysma. There are a series of manoeuvres which
can be applied to this muscle. For some of these techniques
such as a plication, wide undermining is not necessary but
for most of the other procedures, the platysma must be sepa-
rated from the underlying structures to a greater or lesser
degree. There is an easy cleavage plane between the pla-
tysma and the underlying structures.
In dealing with the platysma we take into consideration
the presence of important structures in the vicinity such as
the external jugular vein, the great auricular nerve, the trans-
versal branch(es) of the cervical and facial nerves and the
branch(es) of the mandibular nerves.
4.1.1 Surgical Technique
Having discussed the anatomical considerations, we can pro-
ceed to illustrate the different types of platysma undermining
and the rationale for each. Undermining can be carried out
anteriorly through the submental approach (to be discussed
927
later) and/or laterally. The lateral approach is routinely
adopted in most cervical liftings. It is a rather limited proce-
dure involving just a few centimetres of the lateral part of the
muscle and should not be confused with extensive manoeu-
vres involving the muscle up to the midline which are
employed only in certain specific cases.
Lateral undermining is employed in all cases in which we
want to reposition the muscle or myo-cutaneous flap.
In such cases extensive undermining of the muscle is not
required and it is sufficient to undermining some centimetres
to allow a comfortable mobilisation of the tissue. Often a
lateral section of the platysma accompanies the undermining
to facilitate the repositioning of the flap without tension.
Considering the anatomy of the region, we advise to
approach the lateral border platysma 1–2 cm anterior to the
medial border of the sternocleidomastoid to avoid injury to the
jugular vein and the great auricular nerve (Figs. 6 and 7). If
greater mobilisation is required, we can undermine the muscle
for its entire length, avoiding only the high risk areas. Such
extensive undermining is rarely required and is limited to
those cases in which we need to create a myo-cutaneous flap,
leaving the skin adherent to the platysma. This is a technique
which is reserved for special situations such as heavy smokers,
existence of pathologies of the peripheral vascularisation, etc.
Limited skin undermining is particularly recommended
for heavy smokers or patients with peripheral vascular prob-
lems as it constitutes a less invasive manoeuvre for the cuta-
neous subdermal circulation. These pathologies such as
tabagism, damage from over-exposure to sun, peripheral vas-
cular diseases, etc., are manifested in the cutis through phe-
nomena such as atrophy, slow scar recovery and lack of
elasticity. In these cases, the best option is to intervene at the
submuscular level to maintain an adequate blood supply to
the skin flap.
4.1.2 Why Undermine the Platysma?
There are pros and cons for undermining the platysma.
Firstly, when the platysma is sutured without being under-
mined from the underlying structures, the results of the trac-
tion in time is dependent only on the adherences created in
the sutured area. When the muscle has been undermined, a
much vaster area of fibrotic adherence is created with a
hypothetically greater resistance in time.
Secondly, from a purely mechanical perspective, in a non-
undermined platysma, the force generated by traction on its
posterior margin will be most effective in the lateral areas of
the neck. On the other hand, if platysma is undermined then
this force will extend up to the most medial parts of the
muscle.
This concept plays an important role in favour of
undermining.
If we need to treat hypotone of the platysma in the lateral
neck area or reinforce its laxity in the region caudal to the
928
Fig. 6 The approach to the posterior border of the platysma. To avoid dam-
age to the retroauricular nerve and the external jugular vein, it is opportune
to incise the platysma approximately 1.5 cm medial to the anterior margin
of the SCM. In thin patients the posterior border of the platysma is easily
Platysma
External jugular vein
Fig. 7 Undermining of the platysma for lateral section. Limited degree of
undermining of the platysma is needed to allow its rotation and cranial
anchorage. Once the cleavage place has been located, a Metzenbaum scis-
mandibular angle (e.g. when repositioning a ptotic SMG),
we perform limited undermining of the platysma 2 or 3 cm
from its lateral border.
If instead we need to treat a problem in the anterior part of
the neck and accentuate the cervico-mandibular angle then
we undermine the platysma to a greater extent.
Lateral undermining of the platysma is often associated
with anterior undermining through the submental incision.
Thirdly, undermining the platysma gives greater mobility to
the entire adipo-muscular flap facilitating the relocation of
volumes of tissues from the inframandibular area to the man-
dibular and supramandibular areas. This might be helpful to
augment the volume in the area of the angle and improve the
general aesthetics of the region.
Sometimes we are obliged to limit the cutaneous under-
mining as much as possible for particular typologies of
M.P. Ceravolo
identified; in necks with a greater fat content, we have to look for it by pull-
ing this point upwards using forceps. Creating a small opening through the
adipose layer using Metzenbaum scissors will easily expose the posterior
border of the muscle where our tunnel is to be created
Deep face of the
platysma
External jugular vein
sors is introduced and the area is undermined to approximately 4–5 cm.
The area is then sectioned to facilitate its mobilisation. If all anatomical
landmarks are respected then lesion to noble structures are rare
patients: heavy smokers (more than 40 cigarettes a day for
more than 10 years), patients with vascular pathologies
(acrocyanosis or sclerosis of the microcirculation) and
patients undergoing anticoagulant therapy.
In these cases we undermine the skin to the lateral border
of the platysma and continue beyond, passing into the sub-
muscular layer transforming the medial part of the flap into a
myo-cutaneous one. The myo-cutaneous flap allows the con-
temporaneous mobilisation of the muscle and the overlying
adherent cutis.
In these cases, the platysma must be adequately anchored
by applying a vertical vector whereas the cutis is pulled in an
oblique postero-superior direction. This is certainly a less
aggressive technique than extensive cutaneous undermining
but it can be applied only to selected patients. Considerable
skin excess in the anterior region cannot be rectified by
Surgical Treatment of Ageing in the Neck
limited cutaneous undermining as this may result in inade-
quate remodelling of the submental area.
4.1.3 Traction Vectors
Until some years ago, the most common vector of platysma
traction was an oblique postero-superior one.
This was motivated by two principles: firstly, to pull the
muscle in an opposite direction from its downwards slacken-
ing due to ageing and secondly, due to the presence of the
mastoid region which constitutes a solid anchorage for the ver-
tical pull. A vertical vector was not applied as this would have
necessitated anchorage to the preauricular adipose tissue
which is a weak structure with questionable resistance in time.
The description of the timpano-parotid fascia by the anat-
omist Lorè which was popularised by a paper of Labbè
offered a new solid structure to anchor the platysma, thus
permitting also a purely vertical vector. The two vectors,
oblique postero-superior and vertical produce different
results; the choice of one or another is dependent on the ana-
tomical situation and the objectives to achieve. The oblique
postero-superior vector is most effective on the upper ante-
rior submental area. The vertical vector instead produces a
powerful effect on all tissues located in the anterior and
lower neck regions, giving marked improvements on skin
laxity down to the level of the sternal notch, on the cervico-
mandibular angle and the mandibular border. When Lorè’s
fascia became a viable surgical option our approach to trac-
tion vectors changed and nowadays we mainly use vertical
vectors, leaving oblique vectors for specific cases.
While postero-oblique traction of the platysma does not
always require its lateral section, in the case of vertical trac-
tion, it is opportune to incise the lateral border of the pla-
tysma, providing adequate mobilisation of the tissue
(discussed in detail later) and facilitating flap repositioning.
In addition, vertical suspension gives better definition in the
area of the gonion as the adipose tissue in the inframandibular
area is moved cranially whereas postero-oblique traction is
less effective to this aim as the tissues are moved posteriorly.
Therefore, we can also apply an oblique traction vector in
the case of myo-cutaneous laxity limited to the submental
area. This does not mean that vertical traction is not effective
in these cases. Following the principle of the decomposition of
vectors, specific traction acting on a limited area has greater
effect than diffuse traction on a more extended area. Contrarily,
vertical traction is the option of choice in the following condi-
tions: skin excess in the lower anterior neck, obtuse cervico-
mandibular angle and poorly-defined mandibular border.
Not all cases can be strictly classified within this frame-
work. Sometimes what would be the solution of choice is not
practicable for other reasons. In these situations we must not
only rely on technical details but also follow common sense.
Sometimes a compromise which may favour improvement in
one area more than another is required.
929
4.2 The Sections
Three types of sections can be applied to the platysma:
A. Lateral
B. Anterior
C. Complete
4.2.1 Lateral Section
The lateral section is the most common manoeuvre carried
out on the platysma and has the objective of facilitating both
mobility and rotation of the muscle.
The platysma is incised approximately 4–5 cm below the
lower mandibular rim starting from its lateral border to
approximately 4–5 cm towards the midline.
This manoeuvre is fundamental in treating the SMAS as
it allows traction and repositioning of the platysma without
subjecting it to excessive tension. To be effective, the section
should be associated with other measures aimed at moving
and anchoring the muscle in a new location such as a plica-
tion or imbrication of the SMAS-platysma with a postero-
oblique or vertical vector. These manoeuvres have the effect
of pulling both the muscle and the overlying tissues. If we
wish to pull the platysma in a postero-oblique direction, then
mobilisation of the platysma is not necessary and lateral sec-
tion of the muscle can be avoided. In practice, the only occa-
sion when we do not perform lateral section is when we
anchor the muscle at the mastoid region following a postero-
oblique vector. However, in the vast majority of cases verti-
cal traction is performed and therefore, lateral section is an
indispensable step to mobilise the tissues and anchor them
solidly to Lorè’s fascia (Figs. 8, 9, 10, 11 and 12).
Lateral section is often performed in conjunction with
anterior section even though one or the other may be per-
formed separately.
Indications for a more lateral section (without anterior
section) are the following:
• Hypotonic platysma
• Moderate cutaneous flaccidity in the suprahyoid antero-
lateral neck region in absence of platysmal bands
From a technical point of view, the fundamental stages of
the lateral section are the following:
• Identification of the posterior border of the platysma at a
point 4–5 cm caudal to the mandibular border, anterior to
the sternocleidomastoid
• Exposing the subplatysmal cleavage plane
• Undermining the platysma and creation of a tunnel
approximately 4–5 cm in length
• Incision of the entire muscle layer with scissors or with
electrocautery
930
Posterior border of platysma
Fig. 8 The approach for a lateral section. We can see the same manoeu-
vre on a patient on the operating table. We identify the anterior border of
the sternocleidomastoid and locate the lateral margin of the platysma (in
blue to the left), paying attention to the vasculo-nervous structures present
(retroauricular nerve, jugular vein and in rare occasions, the transverse
Fig. 9 Identifying the posterior border of the platysma. With
Metzenbaum scissors we make a small eyelet posterior to the muscular
border. The tips of the scissors will easily find the cleavage plane
4.2.2 Anterior Section
The anterior section has multiple objectives: it deepens the
cervico-mandibular angle, interrupts the continuity of platys-
mal bands and consequently, their static and dynamic visibil-
ity. Associated with lateral section, it helps improve the
definition of the two segments of the neck.
This is a commonly used manoeuvre and practiced by us on
approximately 50 % of patients. In some cases it is performed
as an isolated technique to remodel a young neck. It is very
often associated with lateral or complete section of the pla-
tysma. Performing this manoeuvre requires extensive under-
mining of the anterior neck and without it acceptable results
M.P. Ceravolo
Mandibular border
cervical nerve). The inferior border of the mandibular angle has been
highlighted with a colourant (to the right). The ideal approach to the pla-
tysma is situated approximately 4–5 cm caudal to the mandible. This
measurement may vary to some degree depending on the height of the
individual patient and on the position of the patient’s head on the table
the SMS-platyma flap
between the muscle and the underlying structures. The scissors must be
oriented towards the midline
cannot be achieved. Due to the wide undermining entailed by
this manoeuvre, contraindications are principally constituted
by vascular problems (heavy smokers, acrocyanosis, patholo-
gies of the microcirculation, etc.) which can compromise the
blood supply to large flaps (Fig. 13).
Indications for anterior section of the platysma are the
following:
• Hypotonic anterior platysma with visible bands
• Ill-defined cervico-mandibular angle
• In the case of a mere anterior neck remodelling non-
associated to a cervico-facial lifting
Surgical Treatment of Ageing in the Neck
Fig. 10 Creating the tunnel and sectioning the muscle. The scissors
create a 4–5 cm long tunnel oriented in a latero-medial direction under-
neath the platysma. This manoeuvre is bloodless if performed within
Cranial border of the lower
platysmal flap
Caudal border of the upper
platysmal flap
Fig. 11 The gap between the muscular borders. We prefer to use scis-
sors rather than cautery to avoid thermal damage to the adjacent tissues.
The platysma has been sectioned laterally but is still intact in its medial
part; after tractioning the platysma a gap is created between the caudal
border of the upper and the cranial border of the lower muscular flap (as
shown by the forceps)
The fundamental steps in this manoeuvre consist in the
following:
• Preoperative planning
• Submental incision of 3–4 cm
• Undermining the submental area
• Identification of the platysmal border and of the type of
decussation
• In the case of a low decussation removing of a portion of
the anterior platysma to transform a low into a high
decussation
931
the natural cleavage plane. The inferior blade of the scissors is inserted
into the tunnel after checking that the deep surface of the muscle has
been freed of any adherences with underlying tissues
• Creation of submuscular tunnels
• Section of the muscle
We can remove transversally a horizontal strip of muscle
to ensure that the incision has been performed to its full
thickness and to distance the edges of the muscular flaps. If
we want to create a more definite demarcation between the
horizontal and vertical neck segment we must also ensure
that any fibrous pseudofascial layer, constituted by the poste-
rior layer of a SMAS duplication, sometimes found adherent
to the deep platysma, has been incised.
If important bands are localised at the medial border of
the platysma, we prefer to remove these surgically for about
4–5 cm in a cranio-caudal direction especially in the pres-
ence of a low platysma decussation. This manoeuvre allows
us to remove the portion of muscular tissue forming the band
and to reduce the horizontal laxity of the muscle. This is also
functional in creating a tonic supporting harness when the
two sides of the muscles are brought together at the
midline.
The section is almost always followed by suturing the
muscular borders at the midline with 2/0 polyglycolic suture
or similar. We prefer to use a braided rather than monofila-
ment surgical suture to avoid the long-lasting palpability of
the latter in time.
The muscular incision can be performed at various
levels.
It is frequently performed at the level of the hyoid bone
when we wish to obtain an acute cervico-mandibular angle
with a clear definition of the two segments of the neck.
We can use a lower section (at the level of the cranial
border of the cricoid cartilage) if we wish to obtain a less
sharp and smoother contour of the profile.
932
Fig. 12 Effect on the anterior and lateral neck. Section, traction and
repositioning of the platysma produces a remodelling effect on the tis-
sues of the antero-lateral part of the neck and improves the definition in
Fig. 13 Section of platysma. We identify the medial platysma borders
and then create a tunnel under the muscle in a medio-lateral direction
using scissors. We, then, section the muscle for approximately 4 cm
This last solution is more indicated in patients with ana-
tomical conditions in which an acute cervico-mandibular
angle is contraindicated (e.g. anteriorisation of the hyoid bone,
prominent thyroid cartilage, prominent and/or ptotic chin).
High sectioning in these situations can give rise to the appear-
ance of inaesthetisms which were not visible in the preopera-
tive period. Although a patient can be satisfied with a partial
improvement, he/she will rarely accept the appearance of a
defect which was not present preoperatively (Figs. 14 and 15).
4.2.3 Complete Section
Undoubtedly the complete section of the platysma is an
aggressive surgical manoeuvre but we believe that in many
M.P. Ceravolo
the region of the mandibular angle. To treat inaesthetisms present in the
anterior region, these manoeuvres must be associated with other more
specific techniques
making sure to incise the entire muscular layers. The submuscular fat is
now exposed. In the case of bleeding, we proceed with careful
haemostasis
cases this is the best option to resolve serious inaesthetisms
of the neck.
Its objectives are to create a net transition between the neck
segments both in its anterior and lateral areas, to correct the
static and dynamic deformities of a hypertonic platysma and its
associated bands, to improve the contour of the neck when more
conservative surgery would not produce any acceptable results.
Indications for a complete section are the following:
• Anterior bands with or without lateral bands and hyper-
tonic platysma
• Short neck which requires lengthening of the vertical
segment
Surgical Treatment of Ageing in the Neck
Fig. 14 High anterior section. Section and plication of the platysma at
the level of the upper border of the thyroid cartilage allows the creation
of a more acute cervico-mandibular angle and a well-defined transition
Fig. 15 Low anterior section in the case of a prominent thyroid carti-
lage. In this case a lower section was indicated by the presence of a
prominent thyroid cartilage. With this typology of patient we have to
• “Difficult” necks (malpositioning of the hyoid bone,
recurrent bands)
• Specific request for an acute cervico-mandibular angle
The complete section of the platysma is normally per-
formed through a combined lateral and anterior (submental)
approach. This can also be carried out entirely via a lateral
approach in certain cases when excessive undermining is to
933
between the horizontal and vertical neck segments. This is the most
common type of section unless there are specific anatomic conditions
which render it inadvisable
make do with a more obtuse cervico-mandibular angle as a deeper angle
would have rendered the cranial border of the thyroid cartilage too
visible
be avoided (heavy smokers or patients who have problems
with peripheral circulation, etc.).
The most important steps in this procedure are the
following:
• Preoperative plan
• Complete undermining of the cutaneous flaps
• Identification of the anatomy of the platysma
934
• Medial section
• Lateral section which is continued to join the medial
section
• Sculpture of the flaps
• Anchoring the flaps
Preoperatively we mark on the skin the course of the sec-
tion to be performed.
When an anterior approach is associated with a lateral
approach the former is carried out first through the submen-
tal approach and then the section is completed via the lateral
approach. We prefer to use scissors for the muscular incision
as diathermy can damage the surrounding tissues.
Once the anterior section has been completed, we proceed
to the lateral section. We identify the lateral border of the
Fig. 16 Complete section on an anatomical specimen. The submuscu-
lar tunnel has been created. There is an easy cleavage plane underneath
the muscle and bleeding is usually absent when this manoeuvre is per-
formed correctly. Once we are certain that the platysma has been fully
Mandibular border
Fig. 17 A sequence of a complete section in a patient. Identification of
the lateral approach. We identify the point to approach the platysma
approximately 4–5 cm caudal to the mandibular border, 1–1.5 cm ante-
M.P. Ceravolo
platysma (see Sect. 4.2.1) approximately 5 cm caudal to the
mandibular border; we create a tunnel along the pre-
established line and incise the muscle and fat layers to their
full thickness to reach the incision previously performed via
the anterior approach (Figs. 16, 17, 18, 19 and 20).
It is of primary importance to section the pseudofascial
layer which sometimes sheathes the deep face of the pla-
tysma. If present and not incised, this structure can contrib-
ute to the recurrence of bands with the appearance of a
“cord-like” deformity in the long run. It is particularly
important in thin necks that the proximal and caudal borders
of the muscular flaps are chamfered (tapered down to a duck-
bill edge). This will minimise the risk of scar tissue forma-
tion along the incision lines which may be visible or felt,
especially in thin-skinned patients.
undermined from the underlying structures, we insert the lower blade of
the scissors into the tunnel and section the muscle to its full thickness to
reach the anterior incision. The two muscular stumps are now com-
pletely separate
rior to the SCM to avoid damage to the jugular vein and great auricular
nerve. The forceps pull the muscle upwards and the scissors create an
eyelet reaching the subplatysmal plane
Surgical Treatment of Ageing in the Neck
Fig. 18 Creation of the submuscular tunnel. The scissors are inserted
through the eyelet and proceed on the underface of the platysma in an
antero-medial direction following a trajectory parallel to the mandibu-
lar border. A blunt technique is advisable when creating the tunnel. We
Mandibular border
Fig. 19 Incising the muscle. The lower blade of the scissors is inserted
into the tunnel and the entire lateral portion of the platysma is incised to
its full thickness. The forceps continue to incise the muscle in a latero-
medial direction to reach the incision made through the anterior
4.2.4 The Levels of the Muscular Section
As far as level of muscular section, we differentiate between
a high and a low section. The first is performed as previously
described, starting from a point 4–5 cm caudal to the man-
dibular border and continues to reach the midline at the level
of the upper border of the thyroid cartilage. The second is
performed along a line parallel to the first but approximately
2 cm lower, at the level of the lower border of the thyroid
cartilage.
There are aesthetic and functional differences between
these two sections.
The high section facilitates the creation of an acute cervico-
mandibular angle due to its positioning at a point where
the internal structures are deeper (subhyoid fossette).
935
have to ensure that the whole muscle has been included in the flap, i.e.
that we are operating in a submuscular and not intramuscular plane. To
the right we can see the tunnel created by the scissors underneath the
platysma
approach. In some albeit rare cases, when we wish to limit skin under-
mining, we can perform the entire section from the lateral approach.
This manoeuvre is not easy as the medial border of the muscle is not
readily identified through the lateral approach
The low section may create a more obtuse angle and is pre-
ferred when we do not wish to deepen the apex of the
angle in order to avoid creating new inaesthetisms. This is
therefore the preferred option in cases of chin ptosis, pro-
truding chin or prominence of the superior border of the
thyroid cartilage.
The functional motivation behind the choice between the
two sections (discussed later in this section on neuromuscu-
lar complications) is based on the important role of the pla-
tysma in smiling: the higher the section, the greater the risk
of impairing the smiling function (Fig. 21).
One of the positive effects of sectioning the platysma
(either at a high or low level) is the increased mobility of the
SMAS which can be moved with greater facility by plication
936
Fig. 20 The gap between the muscular borders. A full muscular sec-
tion associated to the cranial suspension of the posterior flap creates a
gap of approximately 3 cm between the upper and lower flaps. This gap
improves the definition of the transition between the two neck segments
or imbrication. Transposing tissues can be useful to counter-
act the loss of volume caused by ageing in the mandibular
area and consequently, will improve the contour of the man-
dible (Fig. 22).
In certain cases such as patients (thin cutis, sufficient sub-
cutaneous fat and visible platysmal bands), we can opt to per-
form a “tunnel section” of the platysma to avoid creating a
“trench-like” separation between the two segments. After
undermining the skin flap, we create a tunnel approx. 3–4 cm
wide underneath the platysma. We section the muscle by incis-
ing its deep surface, either with a scalpel or diathermic cautery
(DTC) to reach but not incise the subcutaneous fat layer.
This manoeuvre permits us to section the bands while
leaving intact the overlying adipose apron. The muscular gap
is less evident as it is covered by a continuous fat layer and
also due to the fact that the borders of the two muscular flaps
tend to separate less due to the effect of the overlying adher-
ent adipose mantle.
4.3 Sutures
Most aesthetic surgeons with experience in anti-ageing treat-
ment of the neck attribute particular valence to traction of the
platysma. As far as vectors of traction however, Latin saying
tot capita tot sententiae (there are as many opinions as there
are heads) is true. So much so that the opposite sides of this
continuum of opinions tend to propose contrasting ideas:
some sustain that the best option is latero-medial traction
with sutures placed at the midline; others retain that the ideal
solution is a medio-lateral traction with lateral suspension.
Some surgeons believe that, in time, the platysma tends to
form a diastasis at its midline with the consequence that its
M.P. Ceravolo
The borders of the platysma
and highlights the cervico-mandibular angle. We must avoid carrying
out this technique in patients with very thin skin as this may create a
“trench-like” depression on the line of section. In these situations a tun-
nelled section is preferred (as explained later in this same chapter)
medial borders migrate laterally. Following this reasoning,
reconstructing the anterior continuity of the muscle by
medial traction through an anterior plication represents a
valid option. Others believe that the platysma tends to
migrate towards the midline over time; consequently, the
optimal treatment would be to place the muscle under lateral
traction and suspension to recreate its tone. We have experi-
mented with both theories and our experience has brought us
to the following conclusions.
Our objective is to use the platysma to obtain a certain result
which does not necessarily involve recreating the anatomical
conditions of the patient 20 or 30 years previously. We believe
that the platysma as a continuous muscular sheath can help
form a supporting “harness” which helps create a tonic cervical
contour across the entire neck. Therefore, we do not base our
treatment on the application of either a medial or lateral trac-
tion vector but depending on the objective, we take into consid-
eration three different vectors: lateral, medial and vertical.
If the platysma is solid in its medial portion and does not
present any bands then we prefer to adopt lateral traction to
treat its laxity; otherwise we can use both anterior and lateral
pull to obtain a supporting structure to achieve our surgical
goals. Furthermore, considering that facial tissues tend to
slacken in a vertical direction, we should also reposition crani-
ally the fibro-aponeurotic continuation of the platysma (SMAS)
in a vertical direction. Therefore, we have to add a third suspen-
sion vector to the two that we have mentioned previously.
The application of these three vectors entails using three
different suturing techniques for the SMAS platysma:
• Anterior
• Lateral
• Central
Surgical Treatment of Ageing in the Neck
Fig. 21 High complete section. A high complete section can give opti-
mal results in improving the mandibular contour, correcting hypertonic
platysmal bands, deepening the cervico-mandibular and defining the
4.3.1 Anterior Sutures
Anteriorly, the medial borders of platysma can be sutured
together at the midline by the application of various manoeu-
vres (e.g. plication, imbrication, Z-plasty, etc.).
These are aimed to treat muscular diastasis in the sub-
mental area thus rectifying flaccidity of the anterior region.
Applying lateral traction to a reinforced anterior muscular
layer gives additional support to the entire area and helps
remodelling the whole neck contour.
This latter is a necessary manoeuvre to perform in cases
of anterior flaccidity of the platysma and evident high sepa-
ration of the muscle. If we apply only lateral traction in these
937
horizontal and vertical neck segments. However, a frequent conse-
quence of this manoeuvre is that the thyroid cartilage may be empha-
sised in some patients
cases, we might have an improvement in the immediate post-
operative phase. Some months after surgery, however, relapse
of flaccidity is a frequent occurrence. The anterior plication
can be avoided only in the presence of a tonic anterior pla-
tysma without any visible separation, low decussation and no
visible bands (Fig. 23).
The preoperative plan is very important when carrying
out a medial plication. We should identify the anatomy of the
muscle, the position on relaxation and contraction, tone,
localisation of the medial borders, etc. Observing the volun-
tary contraction of the platysma facilitates the identification
of eventual muscular bands. Once the medial borders of the
938
Fig. 22 The low section. Sometimes we may opt for a low section to
create a less sharp cervico-mandibular angle and a less-defined transi-
tion between the horizontal and vertical neck segments. One of the con-
Fig. 23 Midline suture of the platysma with anterior section. Diagram
and anatomical specimen: the suture of the medial borders of the pla-
tysma can be associated with anterior section in certain conditions (i.e.
platysma have been identified, we mark these on the skin to
provide an accurate view of the local anatomy during the
intraoperative phase (Fig. 24).
In the presence of a high decussation and a flaccid pla-
tysma, we remove some excess muscular tissue from the
medial borders of the platysma in a cranio-caudal direction.
During this manoeuvre, we have to remember that in most
cases the muscle will also be tractioned laterally and there-
M.P. Ceravolo
ditioning factors in opting for a low section is the presence of a
prominent thyroid cartilage (such as this case) in which a high section
can over-accentuate the visibility of this structure
anterior bands, hypertonic platysma, obtuse cervico-mandibular angle).
These features are frequent in most patients requiring an anterior
approach to the neck and so this manoeuvre is extremely commonplace
fore we must be conservative to avoid creating excessive ten-
sion in the sutures. Our aim is to obtain a flat, horizontal neck
segment. In order to achieve this, we prefer to leave intraop-
eratively a slight convexity in the horizontal segment which
will tend to disappear over a couple of months with the reab-
sorption of the oedema. A horizontal segment which is
already flat in the intraoperative phase risks becoming con-
cave when the postsurgical swelling abates.
Surgical Treatment of Ageing in the Neck
Fig. 24 Plication with section. A 64-year-old patient with skin and
muscular excess, hypotonic platysma bands and obtuse cervico-
mandibular angle. This patient required a deeper angle and a longer
In the case of high separation of the platysma with a
depression between the medial borders, we prefer overlap
the muscular margins to alleviate this inaesthetism.
When the muscle separates at a medium or low level then
we prefer to remove a more significant quantity of muscle at
the midline followed by approximation of the borders. It is
important not to exaggerate in removing muscular tissue to
avoid creating excessive tension on the suture with the risk of
necrosis of the muscular borders and dehiscence of the sutures.
When the muscle separates at a low level then, we can also
opt for an invaginating plication over the midline without
removing any muscular tissue. This entails not only bringing
the muscular borders together by approximation but also sutur-
ing them in such a way as to bury a pleat of muscular tissue
over the midline, rather like a corset (corsetplasty by Feldman).
The midline suture of the platysma normally starts at the
submental sulcus and reaches the superior border of the
hyoid bone or in some cases, may continue to reach the infe-
rior border hyoid bone or even the thyroid cartilage.
Extending the plication caudally is indicated when we desire
a more gradual transition between the horizontal and vertical
neck segments (Figs. 25, 26 and 27).
Another interesting treatment option for the anterior pla-
tysma is a corset platysmaplasty or corsetplasty (Feldman).
This technique consists in a long, multiple plication incorpo-
rating various layers of platysma carried out from the mental
symphysis to the sternal notch with two or more lines of run-
ning, introflecting sutures. This is a very useful technique
which produces good results and relatively minor risk of dys-
function to the perioral mimic. The technique is based on the
principle of tractioning the platysma with a lateral to medial
vector. The invaginating manoeuvre performed at the midline
creates a greater level of tone in the anterior muscle and results
in a definite concavity of the cervical contour. The technical
939
horizontal neck segment. The ideal treatment option was plication at the
midline associated with anterior muscular section
procedure is as follows: we perform a complete undermining
of the cutaneous flaps placing the two hemifaces in communi-
cation; if required, a lipectomy is performed on the anterior
region. At this point, we locate the medial borders of the pla-
tysma and join them with a running suture to approximate the
muscle at the midline from the mental symphysis.
This suture goes “back and forth” for two or three times
progressively invaginating more and more muscular tissue
with the aim of creating a high-tone plication. This shortens
the muscle transversally and progressively remodels the
neck contour. The greatest quantity of muscular tissue is
invaginated at the level of the hyoid bone where the apex of
the cervico-mandibular angle is.
A corsetplasty can be a very useful manoeuvre and has
both advantages and disadvantages.
The two main advantages of this technique are the
following:
(a) Invaginating the medial borders of the platysma creates
strong adherences, thus giving a more solid support than
the simple approximation of the muscular borders, espe-
cially when dealing with a thin platysma.
(b) The tension created by this manoeuvre deepens the angle
thus avoiding the necessity of a muscular dissection that
carries with it the inherent risk to the facial mimic.
There are also three major disadvantages of this technique:
(a) A long plication entails undermining a wide area of the ante-
rior and lower neck with the risk that this manoeuvre incurs.
(b) If performed as the only treatment for the platysma mus-
cle, latero-medial traction does not improve the contour
of the region of the mandibular angle as it happens when
we associate to it a lateral platysma traction.
940
thyroid cartilage
Fig. 25 A supra- and a subhyoid plication. The hyoid bone constitutes
the lower limit of a high plication (photograph to the left) whereas in the
low plication (photograph to the right), suturing continues to the thy-
Fig. 26 The suprahyoid plication. If performed correctly, a suprahyoid
plication can improve the rapport between the horizontal and vertical
neck segments. This also creates a distinct transition between the two
Therefore, this technique is performed only when there
are no contraindications to extensive undermining (well-
vascularised tissues, non-smokers, etc.).
If the mandibular angle is ill-defined and we need to treat
the lateral platysma then a corsetplasty can be performed on
the condition that we limit the amount of invagination. This
will allow us to associate a lateral pull on the platysma in
M.P. Ceravolo
roid cartilage. The latter manoeuvre is carried out in the female neck to
render a prominent cartilage (Adam’s Apple) less visible
segments and a straight chin hyoid bone line. Both these factors contrib-
ute to improving the general aesthetic(s) of the entire cervical region
spite of the traction created by the invaginating suture which
works in the opposite direction.
The quality of the results are similar those obtainable with
a full platysma section. Due to the lower risk of dysfunction
of the perioral mimic, we tend to prefer corsetplasty over
total muscular section for patients in which the platysma has
a significant role in the smile mimic. The tension created on
Surgical Treatment of Ageing in the Neck
Fig. 27 The subhyoid plication. In this patient we have chosen to per-
form a plication extended to the level of the cranial border of the thyroid
cartilage to avoid deepening excessively the cervico-mandibular angle.
A suprahyoid plication would have overemphasised the already evident
the platysmal harness reduces the visibility of the muscular
bands due to the decreased shortening power of the muscle
during contraction (Figs. 28, 29 and 30).
4.3.2 Lateral Sutures
We have already discussed the two most common traction vec-
tors applied to the platysma: the postero-oblique and the verti-
cal vectors. Each of these vectors has specific functions in
correcting certain inaesthetisms of the neck caused by ageing
but the results are comparable in part. As stated previously, the
effect of the postero-oblique traction vector has its maximum
effect on the upper anterior region of the neck (in the submental
region), whereas it produces no significant improvements in
the lower neck area. This technique has the advantage of requir-
ing little undermining of the platysma but on the other hand,
due to this limited mobilisation of tissue, it does not create any
significant relocation of volume in the area of the angle.
Vertical traction, instead, definitely requires more exten-
sive undermining of the platysma and can produce two
important effects:
1. A remodelling effect on the entire upper and lower ante-
rior neck (including the area above the sternal notch)
2. The relocation of significant volumes of tissue (muscular
and adipose) from the submandibular and infraauricular
areas to a more cranial position, improving the definition
in the region of the mandibular angle
941
mandible, creating an “artificial” rather than the “natural” look which is
routinely requested by the patient. The main disadvantage of the subhy-
oid plication is that it does not produce a straight chin-hyoid line
Obviously, traction is more effective when applied to
previously undermined tissue. Freeing the platysma from its
adherences with the cutis and deep structures is therefore a
propedeutic step before suspending the tissue. We can vary the
extent and localisation of this manoeuvre depending on the
anatomy and the inaesthetism of the individual patient. Lateral
anchorage of the platysma is one of the most commonly
applied manoeuvres in a cervico-facial lifting and is performed
in two different ways depending on the vector chosen:
1. Anchorage to the fascia in the mastoid region to create a
postero-oblique traction vector
2. Anchorage to Lorè’s fascia if a vertical traction vector is
preferred
In the first case, the muscular flap is pulled in a postero-
oblique direction and sutured at the level of the mastoid
region to the sternocleidomastoid fascia or with additional
deep anchorage to the periosteum. We use 2/0 polyglycolic
suture which provides a good level of stability and resistance
but is less detectable on palpation than other materials.
We have to pay particular attention in the area of the mas-
toid fascia to avoid incorporating any sensory branches of
the retroauricular nerve in the sutures which can cause pain-
ful postoperative neuromas. This is not an infrequent prob-
lem when a nerve is sectioned but can also be caused when a
nerve is caught up in a suture. We suggest two useful hints to
942 M.P. Ceravolo

a b

c d

e f

Fig. 28 (a, b) The first layer of running suture. The running, introflect-
ing suture (either 2/0 or 3/0 Polydioxanone) starts immediately below
the mental symphysis and continues in a caudal direction to reach a
point 3–4 cm above the sternal notch. The first stitch is placed 1 cm
from the medial platysma border; this distance is increased progres-
sively to reach a maximum at the level of the hyoid bone. A good quan-
tity of tissue should be incorporated in each bite to minimise the risk of
tearing the muscular fibres. (c, d) The supra sternal notch “pit stop”. We
stop the suture at approx. 3–4 cm above the sternal notch and invert its
direction towards the chin. The needle enters the muscle on both sides
at approx. 1 cm lateral to the previous suture with the aim of progres-
sively increasing the level of tension. (e, f) The second introflecting
suture layer. The suture continues cranially. The distance between each
stitch and the midline depends on the laxity of the platysma: the more
lax the muscle, the greater the distance between the two entry points of
the needle. This distance is usually less in the area of the sternal notch
and increases as we reach the level of the hyoid bone after which it
reduces progressively up to the mental symphysis where it is solidly
tied. On completion of the sutures some irregularities may be visible on
the surface of the platysma. These can be flattened by means of one or
more vertical sutures. It is essential to create a perfectly flat surface,
free from undulations or depressions
Surgical Treatment of Ageing in the Neck
Fig. 29 Result of an invaginating plication (Corsetplasty). A 72-year-
old patient with considerable quantities of skin excess in the anterior and
lateral neck, chin-subhyoid platysmal bands and loss of cervico-
mandibular angle. After the corsetplasty, there is a marked improvement
in the neck. The improvement in the definition of the mandibular angle
help mitigate this problem: place the sutures as far back as
possible so as not to interfere with the course of the great
auricular nerve; ensure that the needle follows a vertical and
not horizontal direction to decrease the possibility of picking
up within the suture a nervous branch which runs in a verti-
cal direction.
In postero-oblique traction, undermining of the pla-
tysma is limited and lateral section is not always performed
as the muscle in this area is already sufficiently mobile for
this kind of traction. On the other hand, when we apply
vertical suspension then the muscle has to be mobilised
extensively to optimise the movement of tissue volumes
from the inframandibular to a more cranial position. This
943
is less evident as no lateral section of the platysma was performed. We
consider corsetplasty as a very useful manoeuvre in many cases but we
have to remember that it is based on a lateral to medial traction. For this
technique to be effective in remodelling the lateral contour of the man-
dible it must be associated with lateral traction of the SMAS-platysma
has the effect of increasing the volume of the angle and
accentuating its definition which tends to become less dis-
tinct with ageing.
In the case of vertical traction, it is sufficient to anchor the
suture after a double passage on the lateral border of the pla-
tysma in the region antero-inferior to the tragus, thus incor-
porating not only the preauricular fat but also the solid Lorè’s
fascia. To include this structure, we have to penetrate to a
depth of approximately 1 cm in patients with an average
quantity of fat tissue; this depth can be varied according to
the thickness of the preauricular tissue. In a patient with sig-
nificant adipose tissue, we will undoubtedly have to pene-
trate more than one centimetre to include Lorè’s fascia in the
944
Fig. 30 Corsetplasty associated with muscular section and lateral sus-
pension. An 82-year-old patient with considerable skin excess, long
platysma bands, loss of mandibular angle and irregularities in the man-
dibular contour. We performed a corsetplasty associated with lateral
section, vertical traction and anchorage of the SMAS-platysma to
Lorè’s fascia. Despite the fact that no anterior section of the platysma
M.P. Ceravolo
was performed, the platysma bands are much less visible on forced con-
traction of the muscle. This technique is particularly suited in cases of
significant muscle and skin excess and mandibular-clavicular bands; it
remodels the neck with limited risk for the perioral mimic but increased
risk for the cutaneous blood supply
Surgical Treatment of Ageing in the Neck
SMAS-platysma flap
Parotid fascia
Fig. 31 Undermining the platysma and suturing technique. Having ade-
quately mobilised the platysma, we place a suture on Lorè’s fascia. The
depth of the bite can vary according to the quantity of adipose tissue pres-
Fig. 32 Anchorage of the SMAS-platysma. We prefer to pass the
suture twice through the SMAS flap to ensure a better hold. The point
of anchorage on the SMAS can vary depending on the degree of tension
that we wish to obtain. The suture should not only include fat but also
some of the muscular tissue. The SMAS tissue is not particularly resis-
suture. Given that the facial nerve is found at a depth greater
than 2 cm in a thin face and at a depth of even 3 cm in a fat
face, this manoeuvre can be performed with a certain degree
of tranquillity.
When we first started to use Lorè’s fascia as an anchorage
point, we used to dissect the area to identify this structure.
After performing a certain number of operations, we decided
to proceed without dissecting the fascia as this same manoeu-
vre could, in some way, damage or weaken this structure.
Unlike the temporal fascia, Lorè’s fascia is formed by a mere
thickening of the connective tissue and therefore, is not
always easily identifiable. This is the reason why we should
not search for this structure but just ensure to fix the suture to
945
Lorè’s fascia
ent in the area. Obviously, in a thin face, the suture will be placed more
superficially than in a face with considerable quantities of fat. There is
little risk of lesion to the facial nerve if the suture is not placed too deep
tant and therefore, should not be subjected to excessive tension which
can cause lacerations in the immediate postoperative period. We should
therefore avoid creating too much tension to avoid a “cheese wiring”
effect of the sutures
a solid anchorage point without placing the sutures too an
excessive depth (Figs. 31, 32 and 33).
Once the needle is in place, by applying tension to it we
have to make sure that the stitch includes fibrous tissue and
not only fat; anchorage to fat alone would not provide suffi-
cient solidity.
After tying the sutures, excess tissue (muscle-adipose-
aponeurotic) in the infraauricular region creates a bulge in
the area. This excess SMAS tissue can be repositioned pos-
teriorly in the retroauricular area by anchorage to the mas-
toid aponeurosis. This will reduce the volume while ensuring
a more stable anchorage. If a certain quantity of excess
adipose tissue is still visible despite this manoeuvre, then
946
Fig. 33 The suturing is completed. A second suture similar to the pre-
vious is added to ensure greater stability to this anchorage. The lower
part of the flap is sutured to the mastoid fascia to avoid any unpleasant
this can be “thinned” by diathermic cautery or excised by
scissors, paying attention not to cut the previously placed
sutures.
This type of anchorage creates vertical traction on the pla-
tysma and can greatly improve the cervico-mandibular angle
and the lateral and anterior lower neck areas.
This manoeuvre is considered essential in remodelling
the deep neck tissues and must be performed in a precise and
meticulous fashion. To maximise its effect, a certain tension
should be exerted on the SMAS-platysma flap. If these
parameters are not met then we can frequently witness a pre-
cocious recurrence of the laxity in the cervical area. On com-
pletion of this manoeuvre and prior to placing the skin under
traction, we have to check whether the surface of the subcu-
taneous layer is perfectly flat. The presence of any irregular-
ity in the contour could jeopardise the final results, especially
in thin-skinned patients.
M.P. Ceravolo
bulge in the infraauricular area and to reinforce the overall stability of
the fixation
When the mastoid area is used for anchorage many
patients report painful sensation for a few weeks; oppositely,
when we apply strong tension on Lorè’s fascia, patients
rarely complain.
4.3.3 Central Sutures
Up until now we have limited all our interventions to the
areas of the platysma caudal to the mandible. We have
already seen how to suspend the platysma laterally and medi-
ally. We can add a third central area of suspension which can
also play an important role in the definition of the neck and
mandible (Fig. 34).
We know that the SMAS layer from muscular transforms
into a fibro/adipose tissue above the mandibular border. This
is the reason why if we want to pull the platysma in a vertical
vector in the anterior facial area we have to apply this trac-
tion to the facial SMAS.
Surgical Treatment of Ageing in the Neck
We believe that the action of the platysma is not limited to
the neck only but is also present in the face. Its continual
contraction creates a downward pull on the tissue in the sub-
malar region. This, together with the effect of gravity and the
other factors involved in the ageing process, tends to dislo-
cate the tissue of the lower third of the face in a caudal direc-
tion. This phenomenon is usually counteracted by applying
plication or imbrication techniques or in specific cases, by
midface lifting. Suspending the SMAS by these techniques
repositions the tissue cranially but this effect is limited by the
continuity between the SMAS and the platysma and by the
downward pulling action of the latter. A good solution to
interrupt this continuity and obviate the downward pull of
the platysma is to section the muscle. This manoeuvre, asso-
ciated with SMAS suspension, can greatly improve any pto-
sis of mid and lower facial tissues and provide long-lasting
effects. An exhaustive explanation of these concepts can be
found in our books on Aesthetic Plastic Surgery of the
Midface and Neck edited by SEE, Florence 2013.
5 The Deep Adipose Tissue
Going from the surface to the depth of the neck, the fourth
layer is constituted by the deep adipose tissue. Underlying
the platysma in the anterior region of the neck is a fat layer
which has slightly different characteristics from the superfi-
cial layer: this is the subplatysmal fat layer. Many surgeons
refer to the term “interplatysmal” which, in our opinion and
also shared by Feldman, appears to be incorrect as this does
not take into account the differing anatomical features of the
platysma in various individuals. For example, in the case of
low decussation of the platysma, the greater part of this fat is
found in a sub- and not in an interplatysmal plane.
Furthermore, also the lateral portion of the deep fat is situ-
ated either beneath the mandible or superior to the digastric
muscle and so it is imprecise to define this as being “interpla-
tysmal”. The deep fat is very similar to lipomatose tissue,
even if it is never encapsulated as happens in a mature
lipoma.
When examining the face, it is important to evaluate the
quantity of the adipose tissue and its localisation in the neck
region.
The quantity of superficial adipose tissue can vary consid-
erably from patient to patient. The thickness of the superficial
fat can vary from a few millimetres to three centimetres or
more; its distribution in the various sectors of the face is
extremely variable and can be influenced by factors such as
weight change and ageing which can cause deflation of tissue
volumes or ptosis. Contrarily, both the localisation and the
quantity of subplatysmal fat layer vary less and similarly to
the buccal fat pad (or Bichat’s fat pad); it remains fairly stable
in time and is influenced marginally by any weight change.
947
The deep fat reaches its maximum thickness at the mid-
line and thins out as it extends laterally to cover the subman-
dibular gland.
Obviously, there are differences both in volume and dis-
tribution between thin and fat faces. In fat faces, the deep
adipose tissue can extend beyond the lateral borders of the
platysma, whereas usually in thin faces the fat extends
laterally no further than 2 cm from the midline. The deeper
part of this fat layer is more solid than the superficial part and
adheres to both the hyoid bone and perihyoid fascia.
The deeper part of the subplatysmal fat is situated between
the anterior bellies of the digastric muscles and is also called
the “intradigastric fat”. We prefer to conserve this deepest
layer of fat with the exception of certain cases such as par-
ticularly obtuse necks.
In the lateral neck, the platysma acts as a division between
the superficial and deep adipose compartments; in the ante-
rior neck, however, this occurs only in cases of very low
decussation of the platysma. In other cases, the superficial
and the deep fat layers are in contact, but separated by a thin
lamina of connective tissue in the entire area where the two
muscles run separately.
Each individual had a different fat distribution between
the two compartments; a fat neck is characterised by accu-
mulations of fat in both compartments, normally with preva-
lence in one or the other.
Although we are dealing with the same type of tissue, it is
important to distinguish between the superficial and deep fat,
both from a diagnostic and therapeutic point of view.
Clinically we can distinguish superficial fat from deep fat
by a series of manoeuvres:
• A static visual examination: the deep fat is localised and
always circumscribed to the anterior part of the neck; its
surface is always regular. Superficial fat is usually more
diffuse and often shows irregularities in its thickness,
especially in the vicinity of the hyoid bone.
• Palpation: the deep fat is decidedly less mobile than the
superficial fat. It is more consistent and dense due to its
lower water content.
• Dynamic examination: the subplatysmal fat moves visi-
bly when swallowing whereas superficial fat does not.
• Voluntary contraction test: if we ask the patient to contract
the platysma, the superficial adipose tissue tends to become
more visible whereas the deep fat, located under the pla-
tysma, becomes less visible. This last manoeuvre is more
effective in patients with a low decussating platysma.
Both adipose layers are obviously present in all patients
but the thickness of each of them may vary. In a neck with
considerable quantities of superficial fat, it not always easy
to quantify the presence of deep fat; in these cases, the defin-
itive diagnosis is made on the operating table.
948
Fig. 34 There are three main directions in which the SMAS-platysma
can be tractioned. The first is lateral to medial applied via an anterior
plication at the midline; the second is medial to lateral applied via
anchorage to the mastoid fascia or Lorè’s fascia; the third is vertical or
cranial, applied by suturing the SMAS to the deep tissues in the zygo-
matic region
In treating this type of inaesthetism, the key element is to
preserve an adequate layer of subdermal superficial fat.
When the presence and the amount of subplatysmal adipose
tissue is responsible of an inadequate cervico-mandibular
angle it should be necessarily treated.
In practice, in the case of considerable excess fat in the
anterior neck, we prefer to perform a moderate, closed lipo-
suction followed by a subplatysmal lipectomy under direct
vision. Any residual volumes can be carefully removed from
the superficial fat layer but always leaving an adequate adi-
pose apron to protect the overlying skin.
In cases of moderate excess fat, we never perform closed
liposuction but always intervene via open field fat sculpting.
The thinner the cutis, the thicker the adipose layer which should
be conserved. We believe that a deep lipectomy should never be
performed by closed liposuction for many reasons:
• It is technically difficult to assess whether the cannula is
removing fat from the deep layer or from the superficial
one and we may easily risk to carry out an inappropriate
removal of superficial fat.
• The deep fat layer is more vascularised than the superfi-
cial layer and therefore poses a greater risk of
haematoma.
• If the cannula is pushed too deep, then it can easily dam-
age the digastric muscles or other deep structures such as
the marginal nerve and the submandibular gland.
• It is very difficult to calculate how much fat the cannula
has removed from the deep compartment and how much
residual fat remains.
M.P. Ceravolo
• Closed liposuction is often performed to avoid undermining
the anterior neck region. The surgeon, in order to obtain a
good cervico-mandibular angle, may voluntarily or involun-
tarily deepen the cannula to remove deep fat without associ-
ating any further treatment of the platysma. In these cases,
and particularly so in the case of a high decussating pla-
tysma, there is a risk of creating a midline depression.
5.1 Subplatysmal Lipectomy
The borders of the platysmal are identified through the sub-
mental incision and are undermined bilaterally for 4–5 cm. We
use scissors or termocautery to dissect and remove, step by
step and conservatively the adipose mass which is generally in
the form of a triangle. It is not advisable to remove the excess
adipose tissue in a single block. Indeed, the fat should be
removed progressively, evaluating step by step the results to
avoid an overly-aggressive lipectomy. It is important to con-
serve the deeper or intradigastric fat which is found between
the two anterior bellies of the digastric muscles. An aggressive
removal of this portion of fat could create a clear cut depres-
sion which may have to be treated through a plication of the
digastric muscles. After removing the fat from the suprahyoid
area, we check the contour of the cervico-mandibular angle
and more importantly, the perihyoid area (Fig. 35).
A second check on the neck contour should be conducted
after carrying out the platysma plication. We frequently
encounter some bulges below the lower end of the plication
which is due to the presence of fat of the middle lower neck
region. Removing this fat will improve the definition of the
apex of the angle.
In terms of risk, an aggressive superficial lipectomy is
potentially more dangerous than a deep lipectomy in that any
damage from the former is more visible and difficult to rec-
tify. Contrarily, any irregularity caused by excessive removal
of deep fat is less visible and normally easier to treat by tak-
ing advantage of the overlying layers.
During a subplatysmal lipectomy, intraoperatively, a ver-
tical depression can appear at the midline. This is due to the
fact that the platysma is open at the midline. This is a tempo-
rary phenomenon and normally disappears when the anterior
plication of the platysma is completed.
The overzealous removal of superficial or deep fat should
always be avoided.
In the case of a too conservative lipectomy, a removal of a
little fat excess is much easier to carry out than the replace-
ment of an excessive removal.
One of the reasons for the frequency of neck irregularities
following overaggressive lipectomy is due to local infiltra-
tion and intraoperative oedema. These two factors create a
pseudo-convexity of the submental area which may push the
surgeon to exceed in the removal of adipose tissue. When
Surgical Treatment of Ageing in the Neck 949

Platysmal borders
a Platysma b

Subplatysmal fat

c d

e f

Fig. 35 (a, b) The submental incision. After performing the submental
incision and generous skin undermining, we carry out a superficial con-
servative lipectomy only in order to expose the medial borders of the
platysma which are then retracted using two Allis forceps to identify
the deep fat layer. Another approach would consist in undermining in a
juxtaplatysmal plane and leave the entire fat layer attached to the der-
mis. (c, d) We commence the lipectomy. Identification of the subplatys-
mal fat. The deep fat is undermined from the deep layer using scissors.
We prefer not to expose the mylohyoid muscle but to leave it covered by
an apron of fat. The deep fat layer is more vascularised than the super-
ficial layer and so immediate haemostasis of any injured vessel is essen-
tial as these tend to retract, rendering this manoeuvre more risky and
complicated. (e, f) Fat removal. We remove progressively a certain
quantity of fat and evaluate the results obtained both visually and by
palpation. We have to be careful to conserve the intradigastric fat. The
depression which sometimes appears after a deep lipectomy may be
hidden by plicating the platysma over the area. However, if the lipec-
tomy has been too aggressive, creating a hollow at the midline, then we
might need to associate a plication of the digastric muscles to compen-
sate the lost volume and to fill out the depression adequately
950
this oedema recedes after a few months then depressions
may become visible. In some patients in whom anterior neck
fat has been treated inadequately, a depression over the mid-
line area is usually accompanied by two lateral bulges in the
paramedian areas. These are normally caused by inadequate
either superficial or deep lipectomy on the midline. During
an anterior lipectomy, the inexperienced surgeon may inad-
vertently remove some deep fat. If a platysma plication is not
carried out then these patients may show a depression in the
central neck area which may appear in the midterm period.
After completing the superficial and deep lipectomies, we
proceed to place the platysma under medial and lateral trac-
tion and then complete the operation by sculpting the super-
ficial fat under direct vision.
Meticulousness is essential in modelling the fat pat, espe-
cially in the submandibular area where oedema of the skin
flap may hide minimal irregularities which may become
obvious postoperatively (Fig. 36).
6 The Submandibular Gland
Submandibular gland treatment during aesthetic surgery of
the neck is a poorly known territory, even if we believe that
this should be part of the armamentarium of an expert
surgeon.
In a retrospective analysis, we calculated that 30–35 % of
patients on whom we performed a cervico-facial lifting had
(to a lesser or greater degree) a visible submandibular gland
in the preoperative phase. Obviously, gland reduction was
not necessary in all cases, but the dimensions of the gland did
influence to some degree the choice of technique
performed.
It has still not been verified whether the prominence of the
submandibular gland (SMG) is due to ptosis or to some form
of hypertrophy (congenital, chronic inflammation, lithiasis,
etc.). The most common problem of the SMG is usually the
spatial relation between the volume of the gland and the
capacity of the submandibular recess. Indeed, in patients
with short or hypoplasic mandibles or with inadequate diver-
gence of the mandibular branches the SMG is frequently vis-
ible, even if it is of normal dimensions.
The protrusion is often bilateral, even if some conditions
such as long-standing inflammatory diseases, obstructive cal-
culosis, etc., can render one side more visible than the other.
During the first consultation, the patient will rarely be
aware of the presence of the SMG, but will often remark on
its visibility after a face-lift; a non-treated gland will tend to
be more visible after neck contouring procedures.
In any case, the surgeon should always point out to the
patient the presence of these bulges in the preoperative phase
and take sufficient photographic documentation to avoid any
postoperative complaints.
M.P. Ceravolo
We must keep in mind that what the patient is told before
the operation is an “explanation” whereas the same informa-
tion given after the operation sounds more like a
“justification”.
We could agree with Feldman’s opinion: there are many
ways to treat a protruding SMG, the most simple of which is
just to ignore it. Although this is the easiest option, it is
often the source of dissatisfaction or even displeasure in
patients. There are other techniques which have been pub-
lished or spoken of such as sclerosing injections or suspen-
sion sutures via an intra- or extraoral approach but with
nebulous results.
There are another three manoeuvres which, for some very
specific cases, can offer some degree of improvement but
these are only used when gland reduction is not a viable
option. These are invaginating sutures, gland repositioning
and platysmal harnessing.
Invaginating or “buttressing” sutures can be considered as
mini-plications performed on the platysma to “push inwards”
a protruding mound. Some colleagues who do not advocate
gland reduction affirm that this type of suture can reduce the
visibility of the SMG. Our experience with this technique
has not given appreciable results in time, except for cases of
minimal protrusion and in presence of a solid platysma.
Gland repositioning: this manoeuvre entails undermining
the gland from its capsule which is then sutured in a more
cranial position to the inner face of the mandible. There are
few surgeons advocating this treatment. We have no direct
experience of this apparently difficult and potentially risky
technique and still harbour some doubts regarding its
effectiveness.
Harnessing the SMG with the platysma consists in trac-
tioning the platysma to create a support to push the gland
upwards so that it nestles underneath the mandible. To ren-
der this manoeuvre effective, we have to remove all adher-
ences between the gland and its anterior capsule. If this step
is not carried out then tractioning the platysma might pull
the gland to a more medial or lateral position (depending on
the vector applied), thus highlighting, instead of reducing,
its prominence. This manoeuvre can be minimally effective
but only in the case of a marginally visible gland. In any
case, a minimal improvement is always better than no
improvement at all. If platysma section is associated with
this manoeuvre then it must be performed in a very low
position. A better option, if we opt to exploit the platysma as
a support, is to perform a corsetplasty, according with
Feldman, adding further invaginating sutures on the pla-
tysma if necessary.
Another useful manoeuvre is based on a “camouflaging”
technique which can be used when a moderate visibility of
the SMG is present in a patient with hypoplasic mandibles.
To understand this possibility let us examine the relation-
ship between the mandible, the hyoid bone and the SMG.
Surgical Treatment of Ageing in the Neck
Fig. 36 A neck with diffuse fat deposits in a younger patient. This
53-year-old patient has a mixed distribution of fat with the greater part
located in the deep compartment. The patient had specifically requested
a much thinner neck with a well-defined cervico-mandibular angle. A
lipectomy was performed on the patient but less conservatively than
951
normal. The addition of a Mittelman Chin-Jowl implant, aside from
correcting the lateromental depressions, was also useful in redistribut-
ing the cutaneous envelope. The elasticity of the skin permitted a more
aggressive lipectomy and was indispensable to achieve the desired
result
952
If we imagine a tangential plane running between the bor-
der of the mandible and the hyoid bone, the visible part of the
gland is the portion which protrudes out through this plane.
In patients with mandibular hypoplasia, the SMG is often
visible as the inadequate projection of the mandible is such
that this hypothetical tangential plane is oriented more verti-
cally. This results in a greater part of the gland being visible.
From this, we can deduce that if the projection of the man-
dibular contour is increased then the plane becomes more
oblique and external, thus reducing the portion of the gland
protruding through the plane.
The prominence of the mandibular border may be
increased by various techniques: by lipofilling, by rotating
local myo-adipose flaps or by using alloplastic materials.
The first technique or lipofilling can be useful to accentu-
ate the mandibular border but is difficult to perform during a
cervico-facial lifting; due to the fact that the skin in this area
is undermined, the fat would necessarily be injected into the
subplatysmal plane which is a high risk area for the man-
dibular nerve, or into the supraperiosteal plane which is not
an ideal site for fat graft survival.
The second technique or local myo-adipose flaps may be
adopted in all case when we want to increase the body and
the angle of the mandible, independently from the presence
of a protruding SMG. This solution does not always guaran-
tee appreciable results, especially in thin patients in which
the scarce adipose tissue renders the construction of solid,
thick flaps particularly difficult.
The third technique, or use of alloplastic materials is indi-
cated only in patients with a hypoplasic mandible and insuf-
ficient adipose tissue in the area to construct adequately thick
flaps. In these cases, implants positioned on the mandible to
increase its projection will render the gland less visible and
can be considered as a valid option. This treatment is also
suitable for patients who, independently from improving the
protuberance of the gland, would also benefit substantially
from an increased mandibular contour.
The best option which gives predictable results together
with adequate improvement in the contour of the area is the
reduction of the gland. Even though this is the most techni-
cally complex solution, it is by far the most trustworthy and
precise solution.
The most important anatomical structures in the vicinity
of the SMG are the following:
• The marginal branch of the facial nerve, running more
than 1 cm cranially in a plane superficial to the capsule
• The lingual nerve, situated cranially and deep to the
mylohyoid muscle
• The hypoglossal nerve, also running in a plane deeper to
the gland
• The facial vein which takes an antero-supero-lateral
course to the gland
M.P. Ceravolo
• The facial artery which follows a deeper course than the
vein to superficialise at the superior border of the gland,
but with frequent anatomical variations
When referring to reduction treatment of the gland, we do
not mean its total removal but simply the removal of a lobe
or a superficial portion of the same.
The main factor to follow in accessing the SMG is that the
approach to the recess must be made by opening the capsule
in the infero-medial portion, respecting the integrity of the
other faces.
Working entirely within the capsule minimises any risk of
lesion to other surrounding structures.
Marking the limits of the gland on the patient’s skin in an
orthostatic position is useful to allow a better identification
of the gland during surgery. In theory, we can use a lateral
approach to the gland but, due to the limited visibility, this
entails greater risk of damage to important anatomical struc-
tures in the area (mandibular and cervical branch, facial ves-
sels). We prefer to adopt an anterior approach via an incision
of approx. 4–5 cm length either in the submental fold or
immediately posterior to this. Some colleagues believe that
this incision should be positioned posterior to the submental
fold to avoid deepening it excessively. Our belief is that the
depth of the fold is not accentuated by the incision and posi-
tioning the incision in the fold helps in reducing its visibility.
Positioning the incision at a distance of approx. 1–1.5 cm
posterior to the fold, however, does allow a wider surgical
field due to the increased proximity to the gland and due to
the higher mobility of the skin. After incising the skin and
subcutaneous fat layer, we identify the medial border of the
platysma and we undermine this from its deep adherences in
a lateral direction. If necessary, removal of subplatysmal fat
during this phase facilitates access to the gland.
We continue the undermining in a lateral direction in the
subplatysmal plane to identify the anterior belly of the digas-
tric muscle. The gland is situated anterior to this muscle in a
sagittal plane. The lateral border of the digastric muscle is an
ideal anatomical landmark to identify the best entry site to
the gland. Once the gland is properly identified, we proceed
to incise the capsule along its infero-medial face.
It is important to leave the antero-superior and posterior
faces of the capsule intact to reduce the risk of damage to any
nerve or blood vessel.
Sometimes there is a well-defined cleavage plane between
the gland and the capsule; in other cases, normally due to
inflammatory disease, we can find adherences which cannot
be removed by blunt undermining. In these cases, it is man-
datory to respect religiously the glandular capsule in order to
avoid damaging the mandibular nerve which runs cranially
and more superficially to the gland.
We advise against using DTC which can cause thermal
lesions, even if applied at low intensities.
Surgical Treatment of Ageing in the Neck
Once the gland has been dissected from the capsule, we
free its superficial lobe using scissors or a long, thin, curved
Crile clamp. To mobilise the gland adequately we have to
free its upper extremity, respecting the mental artery and
vein and the lower extremity which is more mobile and less
adherent to the surrounding tissue.
Before commencing any form of reduction, the gland should
be adequately isolated to allow the resecting manoeuvres to be
carried out safely. If this is not done then even a small intraglan-
dular bleeding vessel may retract deeply, leading the surgeon to
apply a dangerous blind haemostasis. Fibreoptic lights, ade-
quate retraction and suction will help simplify this complex
manoeuvre. At this point we can commence the step by step
removal of the glandular tissue. Even if the glandular lobe seems
to be easily removable en bloc, we rarely remove large quanti-
ties of tissue in a single step. The preferred technique is to
remove smaller quantities progressively, applying meticulous
haemostasis during the manoeuvre and checking the on-going
progress of the reduction.
Once we have obtained the desired contour and com-
pleted all haemostasis then we can apply a fibrin sealant for
greater certainty.
In the majority of cases, it is sufficient to remove about a
half of the superficial lobe to achieve a noticeable improve-
ment. The SMG is relatively larger that what it appears clini-
cally but to achieve visible improvements, normally no more
than one third of its total volume is removed.
We do not close the periglandular capsule; we leave the
inferior portion of the glandular recess open as an exit to
the superficial compartment of the neck area in the case of
postoperative bleeding. This manoeuvre decreases the
risk of compression of the airway by bleeding which may
occur more easily if the capsule were closed. We do not
apply any drains in the recess but only in the subdermal
plane as routinely done after a cervico-facial lifting
(Figs. 37 and 38).
Some colleagues, however, tend to be against this proce-
dure. Obviously, there are some risks associated with this
technique but, if we follow a rigorous procedure and respect
the local anatomy then the complication rate is definitely
limited, as confirmed by our statistics and those of other
experienced colleagues.
Naturally, like all new and complex procedures, it needs a
certain learning curve to be acquired and perfected. Some of
our early results could be considered incomplete as they actu-
ally created more dissatisfaction in the surgeon than in the
patient. On the basis of our experience, we are convinced that
this technique — although not simple — is the only solution in
patients with a prominent SMG to remodel the neck, produce
a well-defined mandible and an adequate cervico-mandibular
angle. Obviously, we have to go through a natural learning
process. SMG reduction is not an easy technique but this is
also true for many other techniques. In 1980, complete section
953
of the platysma or extensive undermining of the SMAS was
considered as being excessively risky manoeuvre. Now, some
years later, these manoeuvres have become “routine” and
almost indispensable in everyday surgical procedures.
Notwithstanding, we discourage that these techniques be
performed by less experienced surgeons but we do believe,
however, that a surgeon who performs frequent face-liftings
can easily perfect these to maximise results in patients with
the right indication (Figs. 39 and 40).
7 The Deep Musculo-fascial Layer
The deep musculo-fascial structures which are most com-
monly treated in aesthetic surgery are the digastric muscles,
the mylohyoid muscles and the suprahyoid fascia.
There exist specific techniques to treat these structures
which are not frequently used.
We will discuss here only about peryhyoid fascia treatment.
8 The Perihyoid Fascia
The removal of subplatysmal fat, particularly the portion situ-
ated in the region of the hyoid bone, exposes a continuous
aponeurotic structure. This fibrous membrane sheaths the
perihyoid muscle: the suprahyoid (both digastric and mylohy-
oid muscles) and the subhyoid (sternohyoid) muscles.
The fascia normally inserts to the hyoid bone, creating a con-
cavity above it which constitutes the apex of the cervico-
mandibular angle. In certain patients with particularly obtuse
angle, the fascia can appear thicker and shows no introflexion at
the level of the bone. This anatomical conformation is often
accompanied by an obtuse cervico-mental angle which is diffi-
cult to correct by other techniques. In these cases, after complet-
ing all the other manoeuvres, we proceed to section the fascia at
the level of the cranial border of the hyoid bone to artificially
create a shallow hollow which can help deepen the angle.
Although technically straightforward, it is also a delicate
manoeuvre in that excessively deepening the incision can
create a tracheal fistula; we believe any surgeon competent
enough to consider deep neck surgery is able to gauge the
correct depth of the incision.
In conclusion, these techniques used to treat the deep
musculo-fascial layer of the neck must be mastered by sur-
geons if they wish to obtain optimal results in difficult cases.
These last techniques, together with gland reduction, rep-
resent a valid instrument to treat specific and otherwise irre-
solvable problems. At the same time, the “deep” techniques
that have been illustrated, if applied too aggressively, may
over correct a defect, giving rise to unsightly iatrogenic
deformities. These manoeuvres must, therefore, be applied
with caution and deliberation (Figs. 41, 42 and 43).
954 M.P. Ceravolo

a b

Mylohyoid muscles Subplatysmal fat

Medial border of left platysma

c d

Digastric muscle
Mylohyoid muscle
Deep fascia of platysma

Deep fat
Subplatysmal fat

Fig. 37 (a, b) Identifying the platysma. If the reduction is performed
together with a cervico-facial lifting, after undermining the anterior
region, we proceed to undermine the lateral sides to create an intercom-
municating pocket. Mobilising the skin allows the flaps to be retracted
and facilitates the visibility of the target area. The left medial border of
the platysma is identified which, in this case is covered with a thin layer
of fat. The left platysma is undermined in a medio-lateral direction
exposing the deep fat compartment. This manoeuvre usually exposes
also the mylohyoid muscle and the medial border of the anterior belly
of the digastric muscle. (c, d) Continuing undermining in a lateral
direction. Once we have completed the deep lipectomy, we continue our
undermining on the mylohyoid muscle laterally which is covered by a
thin layer of adipose tissue. The roof of the tunnel will be constituted by
the deep fascia of the platysma which may or may not be covered by a
layer of fat. The anterior belly of the digastric muscle is located at
4–5 cm lateral to the midline; this is our anatomical landmark to iden-
tify the gland
Surgical Treatment of Ageing in the Neck
Fig. 38 Commencing the resection. We traction lightly the antero-
superior extremity of the gland and commence to resect it with a low
setting DTC to avoid thermal damage to the surrounding tissue. We
never section the base of the glandular flap which is being tractioned so
that we can continue to see its stump in order to prevent this retracting
in the case of bleeding. If bleeding occurs then we interrupt the manoeu-
955
vre and proceed immediately with haemostasis. If the implicated vessel
is not identified then we advise to swab with 1:50,000 epinephrine solu-
tion for some minutes. This will cause a certain degree of vasoconstric-
tion which facilitates a more precise haemostasis, reducing the risk
associated with blind coagulation. DTC should never be used without
verifying what is being cauterised
956 M.P. Ceravolo

Fig. 39 A very prominent SMG in a “short” neck. A complex case of cervico-facial lifting, low plication and lateral section of the platysma
a patient with a very visible SMG, an obtuse cervico-mandibular angle with SMAS anchorage to Lorè’s fascia, anterior section, subplatysmal
and lack of definition between the horizontal and vertical neck seg- lipectomy and plication of the platysma at the midline as well as other
ments. We performed a considerable gland reduction associated with a procedures on the midface
Surgical Treatment of Ageing in the Neck 957

Fig. 40 A particularly difficult case. A particularly complex case with platysma and gland reduction. In cases such as this, any manoeuvre
mandibular hypoplasia and a marked protrusion of the SMG. A cervico- aimed at improving the neck contour but not accompanied by adequate
facial lifting was performed which included the complete section of the gland reduction would have the effect of worsening the neck contour
958
a Hyoid bone
c d
Fig. 41 (a, b) Intraoperative perihyoid fasciotomy. The Adson forceps
lift the fascia which is firmly adherent to the mylohyoid muscle. The
forceps create an eyelet in the aponeurosis, being careful not to deepen
excessively the incision. Once we are in the correct plane, we proceed
to complete the incision of the fascia and repeat the same manoeuvre
contralaterally. (c, d) The fasciotomy creates a suprahyoid fossette. In
Fig. 42 An isolated anterior cervicoplasty in a young 22-year-old
patient with a 2nd class malocclusion who was opposed to an osteot-
omy based treatment. An augmentation mentoplasty was performed
using a FMG (Flowers Mandibular Groove) implant, associated with a
M.P. Ceravolo
b
the photograph to the left we can see a whitish layer of fascial tissue
with no introflection at the level of the hyoid bone; this appears to be a
solid structure in continuity with the bone and creates obtuseness in the
area of the angle. Sectioning the muscle has created a gap between the
hyoid bone and the suprahyoid muscles which tend to retract, creating
a depression useful to create a more acute angle
supra and subplatysmal lipectomy, section of the perihyoid fascia and
plication of the digastric muscles. The photograph to the right shows
the postoperative result 1 month after surgery
Surgical Treatment of Ageing in the Neck 959

Fig. 43 A fasciotomy in a very short and obtuse neck. The section of horizontal and vertical neck segments and with a very low hyoid bone.
the perihyoid fascia during a cervico-facial lifting must be limited to In situations such as this, we have to take advantage of any tools in our
“difficult” necks when other options would not be effective. In this case, armamentarium to obtain the desired result
the obtuseness of the angle co-existed with no definition between the
 Reoperative Surgery of the Face
Bruce F. Connell and Michael J. Sundine
1 Introduction
There has been an acceptance of cosmetic surgical proce-
dures in the general population. No longer is cosmetic sur-
gery only for the wealthy and famous. Cosmetic surgery is
now featured on television, the Internet, and openly discussed
in tabloid magazines. This increased exposure is related to a
significant increase in the amount of plastic surgical proce-
dures being performed. The baby boomer generation has gen-
erally embraced plastic surgical procedures and many of
these patients have had face-lift procedures performed. The
American Society of Plastic Surgeons has estimated that
there were 112,933 face-lift procedures performed in 2008
[1]. While this number is lower than in previous years, likely
due to economic reasons, a substantial number of face-lift
procedures are still being performed. This same population of
patients continue to desire to maintain their more youthful
appearance and therefore they are seeking rejuvenation fol-
lowing an initially successful procedure and thus the topic of
secondary face-lifting is gaining significant importance.
There is a paucity of peer-reviewed literature regarding
secondary face-lifting [2–7]. The published series have very
few patients included in their series. In addition, of the few
patients presented, there are even fewer patients where the
surgeon performing the secondary procedure actually per-
formed the primary face-lift. Cardoso de Castro and Braga
presented a series of 19 patients who underwent secondary
face-lifts [3]. The type of surgery that was performed for the
primary operation was not noted and there was no notation if
any of the 19 patients had the primary procedure performed
by one of the authors. Guyuron et al. [4] presented a series of
33 patients who underwent secondary face-lifting. Of these
B.F. Connell, MD (*)
Private Practice Plastic Surgery, Santa Ana, CA, USA
e-mail: drbconnell@aol.com
M.J. Sundine, MD, FACS, FAAP
Private Practice, Newport Beach, CA, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_67
patients, the senior author only performed both the primary
and the secondary procedure in three patients. The type of
surgery performed at the primary procedure was not pre-
sented nor was the technique of the secondary procedure
noted. The outcomes were based on survey data with patient
recollection defining much of the data. In their series, they
found that the average time from primary to secondary face-
lift was 8.48 years. Morales presented no objective clinical
data in his paper, but does bring out several clinical pearls
regarding secondary face-lifts [5, 6]. De la Torre et al. pre-
sented a series of 14 patients who underwent a re-elevation
of the malar fat pads [7]. The average time to the need for a
secondary procedure was 40 months.
In an effort to clarify further the longevity of a consistent
face-lift technique, the authors reviewed a series of 42 patients
over an 8-year period where the senior author performed both
the primary and the secondary procedures [8]. The average
length of time from the primary procedure to the secondary
procedure was 11.7 years. The reasons for early failure of the
primary procedure were noted as well as any associated com-
plications. There were nine patients who required a secondary
face-lift prior to 5 years from the primary face-lift (21.4 %).
Reasons for early secondary face-lifting (within 5 years of the
primary) included: loss of skin elasticity (five patients),
increase in subplatysmal fat and skin neck folds due to weight
gain (one patient), loss of elasticity secondary to protease
inhibitors for HIV infection (one patient), loss of skin elastic-
ity due to corticosteroid use (one patient), and residual fullness
of digastric and residual submental fat (one patient).
The authors found that a secondary SMAS flap was able
to be elevated in 38 patients (90.5 %). Three patients required
SMAS plication (7.1 %) and one patient (2.4 %) only
required secondary fat contouring. In the patients where a
secondary SMAS flap was elevated, there were two patients
with temporal branch paresis and three patients with a mar-
ginal mandibular branch paresis (11.9 % with nerve paresis).
All of the nerve injuries resolved completely and there were
no permanent nerve injuries. There were no hematomas that
required evacuation. There were no skin sloughs.
961
962
2 Preoperative Facial Analysis
A careful preoperative analysis must be performed prior to
undertaking a secondary face-lift. The secondary face-lift
patient is going to be older and is likely to have acquired
more medical problems since the time of the primary sur-
gery. Indeed, Guyuron et al. [4] found that 42 % of patients
presenting for secondary rhytidectomy had developed a new
medical problem and 58 % of patients had been started on a
new medication since their initial face-lift. Obviously these
patients will need clearance from their primary care doctors
prior to undertaking any secondary procedure.
It would be ideal to have copies of the operative reports from
any previous procedures that had been performed. It is often-
times difficult to get copies of these reports because of the inter-
val of time that has passed from the primary to the secondary
procedure. We also like to have the patient bring in photographs
of themselves at 5–10-year intervals to understand their more
youthful appearance when they felt like they looked good.
We begin with a careful and comprehensive facial analy-
sis. A careful notation is made of the scars from previous
procedures. This analysis also includes a careful analysis of
the hairline of the forehead, temples, postauricular, and
occipital areas. Any distortions of the hairline are recorded
and will be incorporated into the operative plan for the sub-
sequent procedure.
The forehead and eyebrows are examined next. The dis-
tance from the eyebrows and orbital rim to the hairline is
noted. The position of the eyebrows relative to the orbital rim
is documented and the amount of elevation required to
restore the brow to an aesthetic configuration is noted at the
medial brow, midbrow, and lateral brow. An assessment is
made of the amount of transverse forehead rhytids and a rela-
tive assessment of the strength of frontalis muscle contrac-
tion to gauge the amount of thinning that may be required of
the frontalis muscle. The number of creases in the glabella
and their configuration from corrugator superciliaris contrac-
tion is noted as is the number and depth of creases from the
procerus muscle. An assessment is then made of the depres-
sor superciliaris by having the patient close their eyes tightly
against upward resistance on the medial brow.
The upper eyelids are then examined. Many secondary
face-lift patients have previously had blepharoplasty proce-
dures performed. The amount of excessive sagging skin is
noted after the eyebrow has been restored to its appropriate
position. The amount of bulging fat in the medial, central,
and lateral aspect of the upper eyelid is noted. The level of
the eyelid is documented for any possible eyelid ptosis.
Typically the authors have not performed aggressive blepha-
roplasty procedures at the time of brow, face, and neck lift-
ing. A previous aggressive blepharoplasty procedure with a
large skin resection may result in an inadequate brow lift for
fear of creating lagophthalmos with the brow lift.
B.F. Connell and M.J. Sundine
Attention is directed next to the lower eyelids, face, and
neck. A careful assessment is made regarding the amount of
excess skin available for the procedure. The skin laxity that is
found in the secondary face-lift is typically more vertical rather
than more horizontal as is typical with the primary face-lift.
The amount of excess skin is noted anterior to the tragus, ante-
rior to the earlobe, and in the temporal region. An assessment is
made of vertical excess skin in the cheek and both in one half
of the neck and the whole neck. The amount of skin available
needs to be correlated with an assessment of the patient’s previ-
ous incisions and other needs with the secondary procedure
(i.e., creating a preauricular hollow or creating hollowness in
the submental area) to properly plan the procedure.
The lower eyelids are then evaluated. The position of the
lateral canthus, as well as the position of the lower eyelid
relative to the iris, is noted. The tone of the lower eyelid is
noted as well. An assessment of the amount of excess fat in
the medial, middle, and lateral lower eyelid compartments is
made as is an assessment of the amount of excess skin. The
authors have typically avoided lower eyelid blepharoplasty
at the time of face-lifting. A well-executed SMAS face-lift
will improve the appearance of the lower eyelids by about
30 %. Also, with the significant skin and subcutaneous tissue
changes that result from the face-lift procedure, the surgeon
may be tempted to be more aggressive removing lower eye-
lid skin with the possibility of postoperative ectropion.
An assessment is then made of the malar area and the
crow’s feet region. Many patients have fullness in the area
below the infraorbital rim. This is localized edema and it is
not cured with the surgical procedure nor do medications
such as diuretics improve the situation. It is important to
explain this to the patient so that when the fluid and fullness
recur following the procedure, the patient understands that
this is not a failure of the procedure. The soft tissues have
fallen off of the malar eminence in both the primary and sec-
ondary face-lift patients. This ptosis of the soft tissues to the
fixed line of the nasolabial crease leads to an increase in the
size of the nasolabial fold and a deepening of the nasolabial
crease. It also results in a skeletonization of the malar area
and when combined with the soft tissue ptosis in the region
of the mandible, the aging face develops a boxy and angular
configuration rather than the heart-shaped configuration of
youth. The use of the SMAS to reposition the soft tissues of
the face restores the softness over the malar areas and
decreases the thickness of the nasolabial folds [9]. Traction
on the SMAS does not deepen the nasolabial crease.
The presence and severity of crow’s feet are noted.
Undermining over the orbicularis oculis muscle to the area of
the lateral canthus and the lateral aspect of the lower eyelid
will result in a significant improvement in the appearance of
the crow’s feet. In addition, an assessment must be made
regarding the depressor portion of the orbicularis oculis mus-
cle. This portion has been termed as the “depressor orbicularis
Reoperative Surgery of the Face
oculis lateralis” by the authors. When this muscle is strong, it
will oppose any lifting of the lateral brow and will result in
failure of lifting of the lateral brow with the brow lift proce-
dure. The strength of the muscle contraction can be tested by
having the patient smile and apply traction to the lateral brow.
If the muscle action is strong, it can be divided to weaken the
depressor action [10, 11]. When the restraining communica-
tions between the orbicularis oculis and skin (smile creases)
are released, 60 % or more of the lower eyelid excessive skin
is reduced by the shift of the face-lift flaps. If the smile creases/
connections are not released, there is no effect from the face-
lift on the lower lids. The release of the muscle/skin connec-
tions also facilitates the change in direction of the nasojugal
groove from the diagonal direction of older age to the horizon-
tal direction of youth as seen in their earlier photographs.
An assessment of the perioral area is then performed. The
patient is asked to smile and the animation of the perioral area is
observed. This is especially important in the secondary patient
to document the status of the facial nerve preoperatively. The
oral commissures are then evaluated to see if there is a dour (fish
mouth) and downturned appearance of the mouth. Utilization of
the SMAS with adequate mobilization and precise vector place-
ment of the main SMAS flap or a third superior SMAS flap can
elevate the corner of the mouth. The authors prefer this approach
to perioral rejuvenation rather than using excisional approaches
such as those advocated by Weston et al. [13].
The presence of fine vertical lines (smoker’s lines) is also
noted. The author’s treatment of choice for these lines is
dermabrasion at the completion of the face-lift procedure.
Typically the upper lip is treated at the time of the face-lift.
Dermabrasion usually results in improvement of the dark
pigmentation of the lips and better color blending than other
techniques. Phenol peels microscopically show aging of the
skin with disruption of the elastic fibers and collagen. Laser
produces a smooth burned appearance that does not hold up
with continued sunlight exposure. Dermabrasion shows on
biopsy of upper lip skin to show a great amount of collagen
build up, which contributes to the smooth appearance. This is
equivalent to having a filler injected. If circumferential peri-
oral dermabrasion is needed, the lower lip and chin are done
at a second stage some time later. Circumferential perioral
dermabrasion results in difficulty for the patient to open their
mouth in the perioperative period. Finally, an assessment of
the patient’s lips is made and if they are quite thin, the lips
may be augmented with fat grafting or fascial grafts.
An assessment of the chin and neck is then performed.
The laxity of the skin is noted as above. The neck is inspected
for submental scars and their location. Frequently these scars
are actually placed into the submental crease and they must
be disregarded for the secondary procedure. The most infe-
rior level of the skin fold is noted because the extent of the
skin incision in the occipital area is perpendicular to this
crease. The submandibular gland size and prominence is
963
noted. The neck is examined for large digastric muscles that
may create prominence in the submandibular area as well as
interfering with an aesthetic cervicomental angle and sub-
mental area. The presence of jowls and tight mandibular
ligaments is noted. The presence of platysmal bands is noted
and an assessment is made as to whether the bands are tight
and require transection of the platysma muscle. The position
of the cricoid cartilage and thyroid cartilage are noted. The
neck is also inspected for any irregularities that may be pres-
ent as a result of the primary surgery.
Finally, a careful assessment of the ear is performed. The
sensation is assessed to make sure that the great auricular
nerve is intact. The angle of the dangle of the ear lobule from
the axis of the ear is noted. This should normally be 10–15°
posterior to the ear axis [14]. Unfortunately some surgeons
tether the ear lobule anteriorly in a pixie ear configuration.
This is usually as a result of excessive skin removal and a
failure to have placed the ear into the appropriate position
when tailoring the skin at the primary procedure. To correct
this deformity, it requires an additional 4–5 mm of excessive
skin anterior to the earlobe to allow the ear to transpose pos-
teriorly at the time of the secondary procedure. This defor-
mity may not be able to be completely corrected at the
secondary. Patients with long old appearing earlobes with a
deep crease may benefit from a wedge excision of the ear-
lobe. Trimming the caudal margin of the earlobe is best for
long old appearing earlobes without a deep crease [15]. The
length of the earlobe is important if the face-lift makes the
patient appear 15–20 years younger, then the old appearing
earlobes would not be consistent with the younger face.
3 Vectors of Aging
The vectors of the aging face are an inferior lateral and ante-
rior displacement of the soft tissues [16]. These soft tissue
changes are responsible for the characteristic appearance of
the aging face with enlargement of the nasolabial creases and
the development of jowls. The soft tissues seem to fall off of
the malar eminence and the boxiness and angularity of the
aging face. The secondary face-lift, however, has little laxity
in the anterior-posterior direction and most of the skin laxity
is found in a vertical direction. However, this direction of
skin laxity makes it difficult to correct some deformities that
may be the result of the primary surgery.
An example of this problem is seen in the case of the pixie
ear deformity (Fig. 1). In order to adequately correct this
deformity, about 5–15 mm of skin must be advanced
posteriorly in order to transpose the earlobe posteriorly. When
that same patient has fullness in the preauricular area coupled
with the pixie ear, an additional 1 cm of skin may be required
to make a concavity anterior to the tragus, which makes the
skin of the tragus appear thin. Careful attention must be paid
964
to the timing of the surgery informing the patient of what can
be achieved and what cannot be achieved with the secondary
surgery. If understanding is limited, the limitations and pos-
sibilities should be written in a letter to the patient.
Fig. 1 Earlobe pulled forward and inferiorly – pixie ear deformity
a b
Fig. 2 (a, b) Widened scars in the hairline (temporal) – from too much tension on the scar
B.F. Connell and M.J. Sundine
4 Problems Seen After Primary
Face-Lifting
Perhaps one of the most important points that can be made
for face-lifting, which has been presented at teaching courses
for many years by Dr. Connell, is that performing a good
primary face-lift procedure is the key to setting up a second-
ary face-lift. Conversely, a poorly planned and executed pri-
mary face-lift will make it difficult and nearly impossible to
obtain a quality result from the secondary face-lift. The pri-
mary SMAS face-lift technique employed by the authors is
designed to obtain a maximal result from the primary proce-
dure and yet will also allow for the performance of a safe and
aesthetically pleasing secondary face-lift. Those surgical
techniques that are designed for speed using techniques such
as shoving scissors underneath the skin flap will result in
imprecise dissection of the skin flap and SMAS distortion
with the inability to raise a secondary SMAS flap.
There are many problems seen in evaluating patients for
secondary face-lifting that may need to be addressed. Starting
at the temporal area, there may be a widened scar extending
vertically from the root of the helix cephalad into the tempo-
ral hair. A widened scar indicates that there was too much
skin (hair-bearing skin) excised and this may also result in
distortion of the hairline in the temporal area. This may also
result in widening of the distance between the lateral canthus
and the temporal hairline (Fig. 2). Displacement of temporal
hair by non-hair–bearing preauricular skin will result in a
loss of hair, which looks like a widened scar in the temporal
area and may also lead to loss or distortion of the sideburn
area (Fig. 3). The face-lift scar should then pass inferiorly
following the curve of the helical rim and should not be a
Reoperative Surgery of the Face 965

a b

Fig. 3 (a, b) Non-hair–bearing skin transposed into temporal scalp with loss of sideburn

Fig. 4 Scar not following curve of helix
straight line scar (Figs. 4 and 5). Further inferiorly, the scar
should follow the margin of the tragus and should not be
placed anterior to the tragus. Ignoring this point leads to scar
Fig. 5 Vertical scar in front of helical rim rather than following curve
visibility because it ignores the natural color change from the
tragus out onto the cheek and after the skin resection, two
different colors of skin are juxtaposed next to each other
(Fig. 6).
966 B.F. Connell and M.J. Sundine

Fig. 6 Scars placed anterior to tragus with visible color change

For a natural unoperated appearance, a small crescent of

skin must be left attached to the earlobe to preserve the natural
earlobe-cheek junction (Fig. 7). Conversely, one must not Fig. 7 No crescent of skin attached to the ear lobule (incision in the
crease causing an unnatural appearance)
keep too much skin attached to the ear lobule (Fig. 8). In the
postauricular area, the incision should be made close to the
ear-postauricular skin junction. If the incision is onto the con-
cha, a webbing will develop where the incision transitions to
the occipital skin (Fig. 9). Skin removal in the neck should be
mainly in a posterior direction perpendicular to the neck folds.
For eliminating hair shifts, which prevent wearing short
hairstyles and wearing the hair upward, the incisions in the
occipital area should follow the hairline except at the most
posterior aspect where the dog-ear is transposed into the
occipital hair. The incision described in articles and text-
books extending from the postauricular incision into the
occipital hair will often transpose non-hair–bearing skin into
the occipital hair and create an unusual triangular area of alo-
pecia (Fig. 10). Widened scars in the occipital hairline are the
result of wrong direction of skin shift or from excessive skin
resection (Fig. 11). To avoid excessive skin resection, the
cervicomental angle should be at 90° when tailoring the skin.
Great care must be taken to create a natural appearing scar
around the ear. Some of these issues have been touched on
above. The scar should follow the curvature of the helix and
should not be a straight line. The scar should follow the margin
of the tragus and should not be anterior to or behind the tragus.
Fig. 8 Too much skin attached to ear lobule
Reoperative Surgery of the Face
Fig. 9 Web of scar in postauricular area from scar being placed up onto
the concha
Fig. 10 Non-hair–bearing skin transposed into occipital scalp
The skin should be tailored such that the tragus has a definite
beginning and ending (Fig. 12). At the caudal end of the tragus,
the incision should turn 90° and should then turn 90° again to
run along the anterior margin of the earlobe. Many surgeons
make no effort to define the tragus. The tragus needs a concav-
ity superiorly and a color change ending caudally, which sets
the visual height of the tragus. Creation of a depression anterior
to the tragus will make the skin look thin over the tragus.
967
Fig. 11 Widened scars in the occipital hairline
Fig. 12 Tragus without definite beginning or end – also with ptosis of
earlobe
Following a primary face-lift, there may be some contour
irregularities in the neck and there may be some areas of the
neck that were not treated or were inadequately treated. The
platysma muscle may have some tight bands that were not
released. There may be hollowness in the central neck from
over resection of fat. The digastric muscles may have not
been addressed at the primary and will create prominence in
the submandibular area when looking downward or even
when looking straight ahead (Fig. 13). The submandibular
968
Fig. 13 Prominent digastric muscles – also with too aggressive lipo-
suction at inferior border of mandible
glands may be enlarged leading to fullness in the subman-
dibular area.
The hairline must be given great consideration at the time
of the primary face-lift. These issues have been emphasized
above. Many of these deformities can only be treated using
hair transplants [17, 18].
5 Timing
The timing of the secondary surgery will be based on careful
evaluation of the patient. In the author’s series of secondary face-
lifts, the time from the primary face-lift to the secondary face-lift
averaged 11.9 years [8]. There were 9 patients who required a
secondary procedure earlier than 5 years following the primary.
Of these 9 patients, 8 had a significant loss of elasticity of the
skin most commonly due to solar damage, but there was also loss
of elasticity due to corticosteroids and protease inhibitors used to
treat HIV infection. One of the patients had some neck irregulari-
ties associated with a sudden increase in weight.
Ideally the timing for the secondary surgery would be when
the patient is ready for the procedure. However, if there are
significant distortions, for example, the earlobe is pulled for-
ward and there is a lack of a preauricular hollowing, that would
require recruiting significant amounts of skin, it may be pref-
erable to have the patient delay the procedure in order to try to
correct any distortions as a result of the primary procedure.
6 Authors Preferred Technique
The eyebrow position is marked relative to the orbital rim
and then with the brow in the desired position (if a simulta-
neous brow lift is to be performed). The corrugator and
B.F. Connell and M.J. Sundine
procerus muscle creases are marked. Any bulging of the cor-
rugator muscle is marked. If there is strong function of the
depressor portion of the orbicularis oculis muscle, this area
is marked for planned division. The malar pivot point for the
SMAS is then marked. This should correspond to the high
point of cheek projection and is usually a finger breadth
below the lateral canthus. The vertical and horizontal limbs
of the planned SMAS elevation are marked. The mandibular
ligaments are marked as well as the position of the cricoid
cartilage and thyroid cartilage. The external jugular veins are
also marked.
Sequential compression stockings are placed on all
patients prior to the induction of general anesthesia. General
anesthesia is induced using an endotracheal tube that is
placed through the nose. The use of a nasal tube allows for a
more precise correction of the neck. The patient is then care-
fully padded and a Foley catheter is placed. Intravenous anti-
biotics like Ancef are given typically for patients those who
do not have allergies. The scalp, face, and neck are prepped
with povidone-iodine soap and the area around the eyes is
prepped with povidone-iodine solution. After the patient is
draped, local anesthesia solution is infiltrated using 0.5 %
lidocaine with 1:200,000 epinephrine solution. The sensory
nerves are first blocked and then the incision lines and the
lines of planned SMAS incision are blocked. The authors
have not utilized tumescent infiltration because they believe
that it compromises careful flap dissection and may compro-
mise skin viability [19].
The temporal and occipital incisions are planned based
on the amount of skin shift associated with the face-lift.
Frequently in the secondary face-lift, the temporal incision
is made at the hairline to prevent any widening of the dis-
tance from the lateral canthus to the hairline. The preau-
ricular incision follows the curve of the helical rim and then
runs along the margin of the tragus to the color change at
the inferior aspect of the tragus. In the secondary face-lift
patient, a pretragal incision may have to be employed until
there is enough skin recruited to allow movement of the
scar to the margin of the tragus. At the inferior aspect of the
tragus, the incision turns perpendicular and then turns per-
pendicular again to run inferior adjacent to the earlobe. A
small cuff of skin is left attached to the inferior aspect of
the earlobe.
The postauricular incision extends close to the postau-
ricular sulcus until it turns to join the occipital incision.
The postauricular incision where it transitions to the
occipital scalp should usually be made lower than in the
primary surgery. This can be moved more cephalad if the
proper vector of skin shift permits at the time of tailoring
of the skin flaps.
The submental incision is placed posterior to the submen-
tal crease even if the incision was made at the crease for the
primary. Male patients are asked to grow out their beards for
Reoperative Surgery of the Face
Fig. 14 Extent of undermining. The cross-hatched area represents the
regions undermined through the submental incision including the ante-
rior neck, submental crease, chin, and mandibular ligaments
at least 2 days to allow for placement of the incision parallel
to the hair follicles.
The skin is undermined anteriorly only as far as necessary
to permit a different directional shift of the skin from the
directional shift of the SMAS, which is usually in a more
superior direction (Fig. 14). The anterior cheek, which has
connections from the SMAS to the skin, is not undermined
because this would lose a major support of the SMAS to the
incisions in the temporal area and would not make the pleas-
ing concavity that occurs when the attachments from the
anterior SMAS to the skin are left intact. The rotation point
of the SMAS is planned so that there would be an enhance-
ment of the projection over the malar area. The neck is dis-
sected caudally to below the level of the cricoid cartilage.
Through the submental incision, the submental crease and
the osseocutaneous mandibular ligaments are released. No
attempt is made to release the mandibular ligaments in a sub-
SMAS plane.
It is important to take great care in raising the skin flap. If
the flap is raised too thick, the SMAS will be incorporated
into the skin flap. If the flap is raised too thin, there may be a
compromise to the viability of the skin flap. In the author’s
series of secondary face-lifts [8], a secondary SMAS flap
was able to be raised in 91 % of patients whereas plication
was utilized in 7 % of patients due to an inadequate
SMAS. Paramount to raising the SMAS is an appropriate
969
skin dissection. In male patients, the appropriate plane is just
below the hair bulbs of the beard. Female patients are much
more difficult because there may be difficulty in being able
to tell whether one is dissecting in the plane of old scar tissue
or dissecting within the SMAS. The flaps are elevated with a
combination of direct light and transillumination.
Transillumination may be less precise if the skin elevation in
the primary procedure was close to the subdermal plexus of
vessels.
The SMAS flap is then elevated. The amount of release is
performed based on the preoperative assessment of the
patient’s needs. The transverse limb of the SMAS incision is
typically above or at the superior border of the zygomatic
arch and extends medially through some of the inferior por-
tion of the orbicularis oculis muscle and out to the malar
pivot point. The inferior limb of the SMAS incision runs
about 1 cm anterior to the tragus and extends inferiorly into
the neck within 1 cm of the anterior border of the sternoclei-
domastoid muscle. Division of the SMAS is performed
between two Allis clamps that are lifting up on the SMAS to
avoid injury to the facial nerve. The SMAS is then grasped
with the Allis clamps and the SMAS flap is raised before
releasing the zygomatic ligaments and masseteric cutaneous
ligaments. When the desired effect occurs with traction on
the SMAS, the undermining is discontinued. The SMAS flap
can then be advanced posteriorly and superiorly and stapled
temporarily into position. The flap may be bifurcated or tri-
furcated as needed [20].
In the secondary face-lift patient, a SMAS flap can be
elevated in most patients. It may be difficult to raise a sec-
ondary SMAS flap in those patients who have had an anterior
SMASectomy [21] performed because the SMAS is thin in
these patients. If the patient has had the SMAS rolled down-
ward over the zygomatic arch or a Vicryl mesh has been
inserted at the time of the primary surgery, there is a signifi-
cant limitation in the improvement of a secondary SMAS
procedure [22]. In secondary face-lift patients, a pretragal
SMAS flap may not be available to transpose to become an
occipital flap.
Once the SMAS flap has been mobilized, modifications
of the neck are performed. As needed these modifications
include transection of the platysma, defatting of the neck
with open liposuction or direct defatting, removal of subpla-
tysmal fat, tangential resection of the digastric muscle, and
reduction of the submandibular glands. The submental fascia
is approximated and invaginated to prevent hollowing under
the neck. Most secondary face-lift patients require transec-
tion of the platysma below the level of the cricoid cartilage to
improve tight platysmal bands.
The SMAS flaps are then overlapped superiorly to the
temporal fascia and the SMAS flaps are inset. Following this,
two closed suction drains are placed and the skin is tailored.
The skin shift seen in the secondary face-lift patient is more
970
Fig. 15 Postauricular scars due to skin necrosis from pressure
dressing
vertical than posterior. If there is enough skin laxity, one may
be able to get the postauricular skin up to the level of the
previous scar. Skin closure in the temporal and occipital
areas is performed using half-buried horizontal mattress
sutures using 4-0 Nylon. An intradermal 5-0 Prolene is used
in the temporal area. The incisions around the ears are closed
using interrupted and running 6-0 Nylon sutures. Simple
interrupted 4-0 Nylon sutures are used to close the postau-
ricular incision.
The procedure is not completed, however, following the
surgery. The patients are observed overnight with a nurse
at their bedside. They are then able to go home on the
morning of postoperative day 1. They are seen in the late
afternoon of postoperative day 1 where the drains are
removed in most cases. Rarely, the drains will be removed
on postoperative day 2. The patients are seen postopera-
tively on days 1, 2, 5, 7 or 8, and 9 or 10. The preauricular
sutures are removed on day 5. The remainder of the sutures
are removed in the next 5 days. No compressive face-lift
dressings are used because they may lead to skin necrosis
(Figs. 15 and 16).
The patients are given specific activity and wound care
instructions. The patient is not to turn the neck from side to
side, but is to move shoulders and neck as one unit. They are
B.F. Connell and M.J. Sundine
Fig. 16 Neck scars due to pressure dressing
to avoid yawning, but smiling is okay. The patient is not to
have a pillow behind the head, but is to use a small pillow or
towel rolled up and placed behind the neck. The
cervicomental angle should be greater than 90°. The patient
is not to eat in bed, but may eat from a coffee table with one
elbow on the knee. They are to take a liquid or soft diet with
small bites for 10 days. Ice-filled gloves or frozen bag of
peas covered with stockinette to eyelids and crow’s feet
areas are used continuously for 3 days except while eating.
Patient is to lie flat to reduce swelling to the lower eyelids.
The patient should shampoo hair daily for 2 weeks begin-
ning on the third postoperative day using their regular sham-
poo. Water may run over the incision sites, including the
eyes. If patient had dermabrasion of the upper or lower lip,
no ointment of any kind is to be placed on the lips or derm-
abraded area. There should be no driving for 10 days after
the operation. The hair should not be tinted for 1 month fol-
lowing the surgery.
7 Complications
The patients are all given informed consent regarding the
various risks of face-lifting including scars, hematomas,
seromas, skin slough, swelling, bruising, numbness, facial
nerve injury, and sensory nerve injury. The number of com-
plications is surprisingly low. In the author’s series of 42
patients where both the primary and the secondary face-lift
was performed by the senior surgeon, there were no hemato-
mas or skin sloughs. In patients who had a secondary SMAS
flap elevated, there were two cases of temporal branch pare-
sis and three cases of marginal mandibular branch paresis
(11.9 % of secondary SMAS flaps). However, there were no
permanent facial nerve injuries [8].
Reoperative Surgery of the Face
8 Informed Consent
Pearls and Pitfalls
Many of the pearls and pitfalls of secondary face-lifting
have been addressed above. There are a few very impor-
tant points. The surgeon must carefully analyze the
amount of skin available and the skin shifts. The eleva-
tion of the skin flap is critical to both ensure flap viabil-
ity and an adequate SMAS for soft tissue support.
Bibliography
1. American Society of Plastic Surgeons Procedural Statistics, 2008
Report of the 2007 Statistics, National Clearinghouse of Plastic
Surgery Statistics. ASPS
2. Aston SJ, Thorne CHM (1990) Facialplasty. In: McCarthy JG (ed)
Plastic surgery. WB Saunders, Philadelphia, pp 2384–2392
3. CardosodeCasto C, Braga L (1992) Secondary rhytidoplasty. Ann
Plast Surg 29:128–135
4. Guyuron B, Bokhari F, Thomas T (1997) Secondary rhytidectomy.
Plast Reconstr Surg 100:1281–1284
5. Morales P (2000) Repeating rhytidoplasty with SMAS, malar fat
pad, and labiomandibular fold treatment: the NO primary proce-
dure. Aesthetic Plast Surg 24:364–374
6. Bernard RW, Aston SJ, Casson PR, Klatsky SA (2002) Secondary
face lift. Aesthet Surg J 22:277–283
7. de la Torre J, Rosenberg LZ, De Cordier BC, Gardner PM, Fix RJ,
Vasconez LO (2003) Clinical analysis of malar fat pad re-elevation.
Ann Plast Surg 50:244–248
8. Sundine MJ, Kretsis V, Connell BF (2010) Longevity of SMAS
facial rejuvenation and support. Plast Reconstr Surg 126:229–237
971
9. Sundine MJ, Connell BF (2010) Analysis of the effects of SMAS
facial support on the nasolabial crease. Can J Plast Surg 18:11–14
10. Connell BF, Marten TJ (1993) Surgical correction of the crow’s feet
deformity. Clin Plast Surg 20:295–302
11. Connell BF, Marten TJ (1994) Orbicularis oculii myoplasty: the
surgical treatment of the crow’s feet deformity. Oper Tech Plast
Reconstr Surg 1:152–159
12. Connell BF, Marten TJ (1995) The trifurcated SMAS flap: three-
part segmentation of the conventional flap for improved results in
the midface, cheek, and neck. Aesthetic Plast Surg 19:415–420
13. Weston GW, Poindexter BD, Sigal RK, Austin HW (2009) Lifting
lips: 28 years of experience using the direct excision approach to
rejuvenating the aging mouth. Aesthet Surg J 29:83–86
14. Loeb R (1972) Earlobe tailoring during facial rhytidoplasties. Plast
Reconstr Surg 49:485–489
15. Connell BF (2005) Correcting deformities of the aged earlobe.
Aesthet Surg J 25:194–196
16. Yousif NJ (1995) Changes of the midface with age. Clin Plast Surg
22:213–226
17. Radwanski HN, Nunes D, Nazima F, Pitanguy I (2007) Follicular
transplantation for the correction of various stigmatas after rhytido-
plasty. Aesthetic Plast Surg 31:62–68
18. Barrera A (2007) Discussion: follicular transplantation for the cor-
rection of various stigmatas after rhytidoplasty. Aesthetic Plast
Surg 31:69–70
19. Ramirez OM, Galdino G (1999) Does tumescent infiltration have a
deleterious effect on undermined skin flaps? Plast Reconstr Surg
104:2269–2272
20. Connell BF, Semlacher RA (1997) Contemporary deep layer facial
rejuvenation. Plast Reconstr Surg 100:1513–1523
21. Baker DC (1997) Lateral SMASectomy. Plast Reconstr Surg
100:509–513
22. Stuzin JM, Baker TJ, Baker TM (2000) Refinements in face lifting:
enhanced facial contour using Vicryl mesh incorporated into SMAS
fixation. Plast Reconstr Surg 105:290–301
 Suspension Sutures
Franco R. Perego
1 Introduction
The beginning of the third millennium has undoubtedly been
marked by an exponential rise in the request for aesthetic
surgery from ever younger patients who are attracted by the
low invasiveness of these procedures, especially with regard
to the wide range of facial rejuvenation techniques; among
these, the use of the so-called percutaneous “suspension
sutures” represents a choice for all those patients showing an
initial ptosis of the soft tissues of the face, with a slight cuta-
neous excess, as well as subjects of all ages who do not want
to undergo the traditional face-lifting procedure.
This is a crucial point in relation to the problem of facial
aging in present-day patients: the rational working plans of
the surgeon are no longer of much importance (“a musculo-
cutaneous ptosis requires a surgical procedure to detach the
relaxed tissues, fix them in a more appropriate position, and
remove the exceeding part”). What really matters is the fact
that currently our regular patients, of any age and condition,
are unwilling to undergo the risks of a surgical procedure and
even less so do they accept the idea of inevitable postopera-
tive consequences (edemas, bruises, hematomas, and scars)
related to surgery; they actually prefer to obtain lesser results
through recurrent but less invasive procedures.
For these reasons – after the advent of fillers and botox –
we can seriously expect a relevant growth of the clinical
interest in percutaneous tissue suspension techniques: we
can integrate the global rejuvenation of the face with the lift-
ing of ptotic tissues through mini-invasive techniques.
Tissue suspension using surgical threads dates back to
ancient times, even dating back to the Egyptian era when
F.R. Perego
Scuola di Specializzazione in Chirurgia Plastica, Università di
Padova, Padova, Italy
e-mail: info@arsmedicasrl.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_68
thin gold wires were positioned to improve the appearance of
the face, obviously using the technologies of the time.
The first projects concerning special sutures with particu-
lar fixing systems for tissues were in the field of tendon sur-
gery. In 1951, Mansberger, Jenninged, Smith, and Yearger
were the first to come up with a knot-free blocking system
which was able to anchor the two tendinous stumps, thus
lowering the risk of further damage to the tendinous struc-
tures [1].
In 1964, John Alcamo M.D. [2] was the first to patent a
suspension suture with built-in spicules. Then in 1967, two
New Zealanders – Mc Kenzie and Dunedin – divulged the
clinical use of this mono- and bidirectional barbed suture to
fix the two tendinous stumps in the palm as well as the fin-
gers of the hand of a cadaver [3].
The idea of the suspension suture was also applied to con-
verge both sides of the incision in the reconstruction of surgi-
cal wounds, as well as in suturing cutaneous flaps, in order to
lower the incidence of ischemic events [4].
Up until then all the sutures on the market were made of
nonabsorbable materials, due mainly to the enthusiastic reac-
tion to the discovery of an inert synthetic material – polypro-
pylene – which would go on to be greatly successful in all
the fields of surgery [5].
It was as late as 1992 when the American fellow Gregory
Ruff developed a resorbent suture made of polydioxanone
with microscopic projections spirally oriented all along the
length of the thread, and thus allowing the suture of surgical
wounds without knots.
The introduction of suspension sutures in rejuvenating
procedures of the face was very close to being established,
and in 1999, the Russian surgeon Sulamanidze developed
sutures with bidirectional angled hooks. In 2000, he described
a pilot study dealing with the first use of antiptotic suspen-
sion sutures, therefore called APTOS (AntiPTOSic). The
APTOS sutures represent the first generation of suspension
sutures, introducing an extremely important phase in mini-
invasive surgery of the face [6–8].
973
974
2 Normal Anatomy and Local
Microanatomy
If in the practice of conventional aesthetic surgery of the face
anatomic notions definitely prevail over any knowledge in
the field of cutaneous histology (as normally, the surgeon is
worried about preventing any damage to the complex
nervous-vascular apparatus so widely represented in that
zone) using suspension sutures in mini-invasive surgery, a
few details of the microanatomic structure of the upper and
mid-third of the face and of the cervical region represent one
of the main aspects for the success of this technique and for
extending the duration of the results.
In particular, after having a standard series of suspension
sutures inserted into a human cadaver, by passing through an
incision in the scalp of the temporal region, lifting the soft
tissues of the cheek in a satisfactory way and obtaining good
results both in terms of malar volume and of the degree of
cutaneous readjustment, we experimentally created a “histo-
logical mapping” of the suture pathways, performing a series
of full-thickness cutaneous sections along the route of every
single thread until the underlying muscular fascia was
reached; the analysis of the results provided an interesting
sequence of information which is of great importance in
order to perform an optimal implant technique:
• In the temporozygomatic region, in close proximity to
their insertion site, the surgical threads run in a deep
plane, in contact with the muscular fascia.
• However, under the zygomatic arch, the threads run in the
superficial layers of the subcutaneous tissue of the cheek,
reaching a line that goes from the oral commissure to the
mandibular angle; actually, the cutaneous exit points of
the threads are positioned at this level.
• In the superficial layers of the subcutaneous tissue of the
cheek, we have frequently found a higher concentration
of “connective septa,” running between the SMAS and
Fig. 1 Superficial and deep temporalis fascia (Courtesy of F. Perego M.D. and Y. Saban M.D.)
F.R. Perego
the deep dermal layer; in the deep layers, the number of
these septa progressively decreases.
According to this data, in relation to the suspension of
tissues with surgical threads, if the skin has not been
detached, we can deduce that:
Deeper sutures in the subcutaneous plane will obtain lesser tis-
sue suspension.
This conclusion definitely represents a certainty which
has never been cited before in the literature regarding the
various techniques utilized in the implant of suspension
threads, whatever their nature and the technique utilized to
avoid the detachment of the cutaneous layer.
Another relevant anatomic detail which is well worth con-
sidering in order to perform the abovementioned procedure
with the greatest standards of safety: the facial nerve is expected
to cross the direction of the threads, from the temporal region
to the zygomatic arch and from the deep fascial plane to the
subcutaneous layer, and the temporofrontal branch of the VII
nerve, cranially to the zygomatic arch, runs between the two
sheets of the superficial temporal fascia [13]; thus the only way
to prevent any accidental damage to this structure consists in
passing a superficial stitch that enters the subcutaneous layer at
the insertion of the temporal scalp (in a site definitely proximal
to the course of the nerve), letting the facial nerve branch run
the rest of its course toward the cheek below that point, which
is well shielded by the temporal fascia (Fig. 1).
3 Surgical Techniques in Use
Aptos sutures are made of polypropylene and are applied
percutaneously without any surgical procedure. The two
extremities of the suture have a bidirectional orientation that
allows the locking and compression of the fibroadipose layer,
in order to squeeze and lift the engaged tissue.
Suspension Sutures
We can say that all the successive suspension sutures
were born from this idea. Once the pros and cons were evalu-
ated, the different sutures and surgical techniques which
would improve the results while at the same time reducing
the complications were presented.
The second generation of suspension threads for the sur-
gery of the face includes sutures with unidirectional “spic-
ules”; actually, these do not represent a real innovation, as in
1967, Mc Kenzie had already planned their clinical use in the
repair of tendons. The distal spicules are fixed to the fibro-
adipose tissue with a strong and safe fastening of the proxi-
mal tract of the thread to a rigid structure; in this way, better
and longer-lasting results with fewer complications can be
obtained. These polypropylene or absorbable sutures are
inserted by means of a surgical procedure – even if this is of
limited impact – whose clinical applications can be extended
if combined with an “open” and/or endoscopic approach.
Fig. 2 Silhouette suture with cones
Fig. 3 Formation of neocollagen fibers around the shaft of the suture and its knots; disaggregating cone (Courtesy of J. De Benito M.D.)
975
The sutures and the techniques successively presented by
Sasaki [9] – Woffle Wu [10] and Isse [11] – as well as the
midface applications recommended by Malcom Paul [12],
confirm the versatility of this device.
In 2004, the American FDA (Food and Drug
Administration) approved the barbed contour threads; ini-
tially, this monodirectional suture was made of polypropyl-
ene, while later on, it was produced using polylactic acid and
was resorbent.
The third generation of suspension sutures for the surgery
of the face was born from an idea Al Kolster (Kolster
Methods, Corona, CA) came up with. While he was
marketing different types of suspension sutures, his constant
research into a more efficient anchoring system in the fibro-
adipose tissue brought him to develop cones instead of “spic-
ules”; this was the origin of the Silhouette [15] sutures. The
structure of the thread with its spicules was modified creat-
ing a new, hybrid, device with a polypropylene base (the
thread) and six cones, each precisely spaced between little
knots made of resorbent polylactic acid, acting as a tempo-
rary anchoring system (Fig. 2). The cones are absorbed after
about 1 year, and in their place, they leave a strong fibrotic
tissue around the thread and its knots, with a lasting support-
ive effect on the fibroadipose tissue (Fig. 3).
As we will see in the present chapter, the Silhouette
suture, which was approved by the FDA in 2006, acts as a
unidirectional suture which allows a solid fixation to the
deep temporal fascia. The initial applications of this tech-
nique were developed by Nicanor Isse M.D. from Newport
Beach, CA, while Franco Perego M.D., Roberto Pizzamiglio
M.D., Mabel Gamboa M.D., and Louis Vasconez M.D. all
introduced technical variations in order to obtain better and
longer-lasting results; they also suggested other interesting
applications, such as the use of static suspension in the treat-
ment of facial nerve palsies.
976
4 The Author’s Technique
For a few years, I utilized sutures with unidirectional spicules,
usually in order to perform the endoscopic lifting of the supe-
rior and middle third of the face, aiming to reduce the required
area of detachment below the zygomatic arch; I always obtained
satisfactory results in augmenting the zygomatic volume and in
partially correcting exaggerated naso-genial grooves.
The results obtained using only these sutures, without lift-
ing a SMAS flap in the temporofrontal as well as zygomatic
region, had an outcome that was too short in its duration, and
thus I was forced to give up this technique, going back to the
association between Prolene sutures with monodirectional
spicules and an endoscopic lifting. What was actually miss-
ing, as I realized later, was a more solid fixation of the spic-
ules to the fibroadipose tissue, as these were too weak to
sustain both the load of the gravitational force combined
with the traction of the mimetic muscles (Fig. 4).
Starting from 2006, I started to implant the new Silhouette
sutures, whose spicules had been substituted by special hol-
low cones with the capacity to sustain the weight of the tis-
sue for long periods of time (a few years); I have progressively
modified the implant technique, and today I have actually
standardized the ideal surgical technique to be applied in the
face and in the neck.
The procedure is performed under local anesthesia, with
mild sedation.
4.1 Silhouette Lift of the Face
In the preoperative planning, the patient is examined in the
sitting position; with him/her help, we proceed to select a
“dominant vector” for the lifting of the cheek, more or less
vertically oriented in relation to the intent and the patient’s
wishes; four suspension stitches are thus marked out; one of
these is positioned laterally to the naso-genial groove, a sec-
ond one in the proximity of the oral commissure, and the
other two along the line running between the oral commis-
sure and the auricular lobule insertion, placed at an interval
of nearly 1.5 cm. A 1.5–2 cm incision is made on the tempo-
Fig. 4 Schematic representation of the thread with its spicules: cleav-
age point
F.R. Perego
ral scalp (Fig. 5), parallel to the zygomatic arch; then a small
pocket is created directly over the deep temporal fascia
(DTF), and a Prolene mesh stripe (1 × 2 cm) is fixed over it,
in order to obtain a maximal strengthening effect for the
stitches and to prevent any potential laceration of the fascia.
A straight pilot needle (protected by a blunt introducer) is
inserted in depth until reaching the DTF, and then it is pushed
into the subcutaneous layer toward the insertion of the scalp;
the surgeon gently palpates the needle point with his finger-
tips and then pushes it progressively under the skin, to then
extract it as soon as it reaches the level of the pre-marked
suspension sutures. The suspensive effect is created by knot-
ting the stitches in pairs and then fixing the corresponding
knot onto the Prolene mesh, thus obtaining a stronger hold
and greater symmetry; the different layers of the wound are
sutured, and the face is lifted using a simple elastic bandage
that the patient can tighten at her will.
Usually, in the postoperative period, only a slight edema and
minimal bruises can be noticed, so after 2 or 3 days, with the help
of makeup, the patient can go back to his/her social activities.
Over the first 1 or 2 weeks chewing, can cause some dis-
comfort, but this is never a problem as our patients are always
pleased to go on a light diet.
Unfortunately, even though this procedure may seem very
simple and suitable for everyone – whether they are surgeons
or patients – this is not the case; in reality, it involves a few
particularly complex problems regarding both various tech-
nical details as well as the extremely strict criteria used in the
selection of the patients, but above all of eventually exclud-
ing certain patients from the procedure.
In relation to technical details, according to data from my
personal records and international data based on 15,000 cases
operated on by international surgeons, we have actually
attained remarkable expertise, and we now definitely possess
the so-called tricks of the trade which will be described and
referred to in the “Pearls and Pitfalls” section.
Fig. 5 Surgical incision in the temporal area, with the exit points of the
four standard sutures utilized for the facial lift
Suspension Sutures
On the other hand, I believe that evaluating the indica-
tions and contraindications to this procedure and learning
how to associate different procedures are just as useful as
acquiring the technical skills. The least possible invasiveness
is always mandatory.
The ideal patient shows initial signs of periorificial loos-
ening, with partial lengthening and flattening of the orbito-
malar region, overloading of the naso-genial grooves, and
slight compliance of the mandibular profile; the patient must
still be young (Fig. 6 pre- and post-op), or at least must have
a young “dermic age,” and with skin of medium thickness,
sufficiently elastic and must have a reasonable amount of
subcutaneous tissue: in these cases, the “Silhouette Lift” has
always proved to be an effective technique bringing great
satisfaction to both the surgeons and the patients (Figs. 7 pre-
and post-op; 8 pre- and post-op).
However, the vast majority of patients requesting facial
rejuvenation are over 45 years old and with a “border line” or
definitely damaged quality of the skin; furthermore, they
almost always complain about an exaggerated labiomental
fold (the so-called marionettes), often in combination with
platysma bands under the chin.
Fig. 6 Silhouette Midface-Lift: pre- and postoperative results (1 year after the procedure)
977
In these cases, when patients refuse a traditional face-lift,
the sole use of suspension sutures as the only procedure will
bring about poor and short-lived results; on the other hand,
what has brought about excellent results in the treatment of
the face is to combine the use of the Silhouette sutures with
one of two possible surgical procedures:
• A neck-lift by means of a retroauricular mastoid incision
• The conservative removal of the preauricular cutaneous
excess, performed after the threads have been definitely
positioned, avoiding any cutaneous partition
It is a verified fact that patients undoubtedly prefer to have a
short preauricular scar which can be easily concealed with the
use of makeup after a week or so, before waiting for its natural
reduction, as well as the swelling and bruises in the cervical
region, which can also easily be hidden by wearing the right
clothes or hairstyle, rather than undergo the unpleasant conse-
quences which often result after a traditional face-lift.
In brief, it is necessary to describe the potential results of
the procedure with the greatest precision, even at the risk of
forgoing this surgical option; mastering any association of
978 F.R. Perego

Fig. 7 Silhouette Face- and Neck-Lift: pre- and postoperative results (2 years after the procedure)

Fig. 8 Silhouette Face- and Neck-Lift: pre- and postoperative results (18 months after the procedure)

techniques can be of help; the results may be less radical,
though tangible, and, in any case, will be respectful of the
patients’ more than legitimate demand to look younger but
without wanting to face a long and psychologically demand-
ing postoperative period and at the same time expecting a
quick return to their social activities.
4.2 Silhouette Neck-Lift
Usually, the Silhouette sutures are positioned deeper in the
subcutaneous layer, and the superficial temporal fascia is
often involved; a retroauricular cutaneous incision is per-
formed, and two suspension stitches are passed on the
median line, in the suprahyoideal region; the cervical flap is
readjusted, creating an effective suspension, with a more
favorable cervicofacial angle; the platysmal bands are simi-
larly reduced.
In fact, previous experiences demonstrate that a strong
traction on the threads is penalized by the constant rotations
of the neck, and thus any result is impeded in a short time.
A meticulous readjustment of the tissues, particularly if
performed in conjunction with a selective liposuction of the
cervical and/or mandibular fat tissue, definitely gives better
Suspension Sutures 979

Fig. 9 Silhouette Face- and Neck-Lift and Liposculpture of the neck: pre- and postoperative results (1 year after the procedure)

and longer-lasting results. According to my personal experi-

ence, which is also supported by international literature
(M. Gamboa M.D., L.Vasconez M.D. [13], E. Bisaccia M.D.
[14]), the implant of surgical suspension threads into the
neck can be integrated very well with a liposculpture in this
region, thus greatly improving the elastic retraction and the
fibrosis induced by liposuction (Fig. 9).
The ideal patients for this procedure are those with
moderate cutaneous elasticity, which is easily detected
with a snap test; a medium thickness of the skin is prefer-
able, as it prevents the emphasizing and/or palpability of
the cones as well of the threads; patients with significant
laxity or excessively thin skin are to be considered poor
candidates.

Fig. 10 Technique of re-tensioning: intraoperative appearance

4.3 Later Re-tensioning

All the techniques dealing with the first generations of

suspension sutures with spicules share a common draw-
back which relates to the duration of the results; the case
reviews in the literature clearly show that when using
sutures with mono- or bidirectional spicules, passed in the
depth of the tissues and fixed or not to deep structures,
after the initial astonishing results shared by the various
procedures, the technique invariably fails in the course of
the first 6 months or, at the most, after the first postopera-
tive year.
According to our previous detailed analysis, the reason
for this is almost certainly due to the weakness of the spicu-
lar fixing system; the introduction of the cones has definitely
extended the durability of these results; nevertheless, our
desire to prolong the corrective effect of the procedure, for as
long as possible, led us to seek a suitable expedient. Once
this had been tested and codified, it was successfully utilized
in many patients, and we decided to call it “Re-tensioning
technique.” It simply consists of the reopening the temporal
scar and isolating the Prolene mesh that – depending on the
time that has passed (2 or more years) – can appear more or
less embedded by a solid block of fibrous tissue; at this point,
it is possible to mobilize the two knots that we will find in
close contact with the mesh and to re-tension the sutures;
these will be fixed in a more cranial position using a stitch
made of a loop of Prolene (which is preferable to Nylon due
to its greater elasticity) (Fig. 10).
980
We usually obtain an average lifting effect of 1.5 cm; the
procedure can be performed in the outpatient clinic, under
local anesthesia, allowing the subject to immediately resume
her social activities without any edema or bruises; the only
referred complaint can be a minimal discomfort while
chewing.
4.4 Static Suspension in the Facial
Nerve Palsy
In this particular application, the same incision site of the
fixing sutures on the deep temporalis fascia is utilized; the
stitches are organized in a special trapezoid pattern
Fig. 11 Trapezoidal placement of the Silhouette threads in a patient
with facial nerve palsy
Fig. 12 Static suspension in a patient with facial nerve palsy: pre- and postoperative appearance
F.R. Perego
(Fig. 11): one or two pairs of Silhouette sutures are linked
distally and knotted in correspondence to the naso-genial
groove; in this way, a strong suspensive segment is created
which is able to maintain its lifting effect on the oral com-
missure and on the paralyzed cheek in the same way that
the trapeze bar holds up the circus performer during his
evolutions (Fig. 12).
To correct the paralyzed hemi-lip deviation and to further
sustain the oral commissure, a different pattern of the
threads is organized, similar to the one commonly utilized
in correspondence of the fascia lata strip, with two exit
points, respectively, in the areas of the superior labial filter
and in the chin dimple (Fig. 13). As this technique is virtu-
ally noninvasive, it is particularly useful for aged patients
who aspire to a better social life with the least surgical
involvement, but also for younger subjects who for various
reasons do not wish to undergo those “dynamic” procedures
[16, 17] that are in any case still the first surgical choice for
patients of this age.
5 Complications
In general, the most common complication in surgical
procedures using sutures with spicules is the extrusion of
the thread after a variable length of time from the implant;
this is due to the intrinsic structure of this generation of
sutures, with their spicules representing their weak point
and “Achilles heel.” Once the tissue has been hooked and
the suture tensioned, a cleavage is created in the point
Suspension Sutures
Fig. 13 Schematic positioning of the Silhouette threads “stripe-like
fascia lata” in a patient with facial nerve palsy
where each spicula actually stems from the suture body;
thus, the tensioning effect is inevitably lost causing the
possibility of the thread migrating and being extruded at a
later time.
Owing to the introduction of the cones, the third genera-
tion of sutures is completely free from this complication or
any other major complications worthy of note.
However, problems related to the learning curve of the tech-
nique or others related to malpractice must be pointed out:
• Intraoperative rupture of the suture: it may occur while
the two threads are being tied in an over the mesh knot,
trying to achieve the required tension; to prevent any rup-
ture, it is sufficient to apply tension progressively on the
sutures before the knot is tied. The tying of the knot will
be safely concluded only after its placement directly on
the mesh.
• If the suture breaks, its removal in the distal to proximal
direction is both difficult and traumatic; it is better just to
cut its proximal end and apply a new stitch.
• Hematoma formation after puncture with the pilot needle:
these hematomas are usually rare and of limited entity;
they can be perfectly controlled by applying manual com-
pression. They have practically disappeared after a spe-
cial blunt introducer became available.
• Postoperative detection of excessive tension in one or
more threads: this problem can be due to an erroneous
intraoperative evaluation by the surgeon in the course of
the operation and appears to be rare and is always limited
981
Fig. 14 Erroneous placement of the Silhouette threads; the cones are
clearly visible at the intradermic level
to cases of inexperience during the first procedures. To
solve the problem, it is necessary to make a new opening
of the incision, which is possible in the outpatient clinic
under local anesthesia with 2 cc of lidocaine; the Prolene
mesh is easily evidenced and the suture(s) responsible for
the undue tension can be sectioned. It is not necessary to
remove the stitches, but they must be replaced with others
with the exact degree of tension.
• Postoperative detection of one or more cones at the
intradermic level and their visibility and palpability:
this is evidently due to malpractice by surgeons who
are inexperienced or unaware of the technical details.
In these rare cases, with the thread in the wrong plane
(Fig. 14), the only solution is the removal of the suture
which is concerned by means of a cutaneous micro-
incision in close proximity to the more distally placed
visible cone; the suture must be sectioned proximally at
the level of the initial temporal incision, thus allowing
the easy removal of the thread in a proximodistal
direction.
• Postoperative detection of shallow cutaneous dimples:
the adhesions may simply disappear after a gentle mas-
sage; otherwise, a period of careful inspection with
weekly checkups is advisable. Usually, the problem is
due to the temporary adhesion of one or more cones to
the deep dermal layer (Fig. 15) which clears up spontane-
ously with a progressive recovery in the course of
2–4 weeks. The patient must be reassured and informed
that the problem will be quickly resolved, but it is neces-
sary to avoid applying forceful digital pressure, as these
maneuvers would definitely detach the cone from the der-
mis, but would also bring about the failure of the
procedure.
982
Fig. 15 Temporary adhesion of one of the cones to the dermal layer
Pearls and Pitfalls
As in any surgical procedure, the use of suspension
sutures with cones requires the knowledge of a few
technical details of the utmost importance, especially
regarding a technique from which both the surgeon
and the patient expect excellent results from practi-
cally minimum surgery. The sharing of our experience
with other international surgeons of great repute has
allowed us to combine a series of cardinal points lead-
ing to the correct and effective carrying out of the
Silhouette Lift of the face.
The cutaneous exit points of the first pair of suspen-
sion sutures that selectively suspend the malar region
and the oral commissure must always be positioned at
least 0.5–1 cm from the naso-genial groove, to avoid
its deepening instead of its distention.
Sutures must not pass through areas with particu-
larly thin skin, such as the orbital area and the classic
parotic-masseteric “depression.”
It is necessary to position a strip of Prolene mesh
sutured to the deep temporalis fascia within the tempo-
ral incision, in order to prevent any microscopic lacer-
ation that would jeopardize the supportive effect of the
stitches.
The use of the special blunt introducer makes the
technique simpler and safer and prevents the develop-
ment of hematomas and any lesions to the neural
structures.
Cones must not be positioned in correspondence to
the zygomatic arch, where they could block, curtailing
the effects of the suspension as well as creating
unsightly cutaneous wrinkles. Once the first stitch has
been passed and the pilot needle has been extracted at
F.R. Perego
a level that makes the first knot visible (remember that
cones and minute knots actually alternate), it will be
sufficient to measure the exact distance between the
knot and the zygomatic arch, extracting the corre-
sponding number of knots, knowing that every suture
bears six cones positioned 1 cm apart from one another.
The tension exerted on the flap must never be tested
with the first suture tied in place, as this maneuver
could cause the fixed tissue to “slip” on the cones,
loosing valuable mms or cms of suspensive effect; the
suspension must only be tested after all the sutures are
in place.
At the end of the procedure, before the definitive
suturing of the incisions in the temporal region, it is
necessary to lift up the backrest of the surgical table so
the patient is in a semi-seated position, and the skin
must be observed with great care; what may appear
perfectly homogeneous in a position of clinostatism
may sometimes disclose one or more depressed areas
or deep adhesions, requiring an immediate treatment
and the simultaneous substitution of the suture.
Liposculpture can be potentially added in the neck
area: this technique must always preserve a layer of
adipose tissue whose thickness must be sufficient to
prevent visibility and palpability of the cones and at
the same time avoiding any excessive thinning of the
skin.
Informed Consent
Informative Document for the Silhouette Lift Procedure
Subcutaneous Suspension of the Face and Neck with
Silhouette Sutures
Patient’s name and surname……………………..
Received on……………………………..…………
1. What is the Silhouette Lift? It is a mini-invasive surgical
technique that uses the Silhouette Lift sutures for lifting
the soft tissues of the face and neck; these are special
polypropylene (a non-resorbent material, widely utilized
in surgery) threads with minuscule hollow cones of resor-
bent material built along their structure.
For the face, the threads are introduced through a short inci-
sion on the temporal scalp and directed subcutaneously
toward the cheek following a specific framework; when
the traction is exerted toward the temporal region, the
cones hook the soft tissues, lifting them to the desired
level; the sutures are then fixed with a couple of stitches
to the temporalis fascia, whose tough resistant tissue is
able to sustain the traction.
Suspension Sutures
For the eyebrows (tail), the threads are positioned through
minimal incisions in the scalp in the frontotemporal and
superaciliary regions.
For the neck, the threads are positioned through a short inci-
sion behind the ear.
2. Indications: this technique is particularly efficacious in
the correction of early signs of aging of the face and can
therefore be more suitable for persons of a younger age
compared to patients who are customarily interested in
more radical surgical procedures, such as the traditional
face-lift.
It is also recommended for all those patients requiring minor
corrections of slight facial defects, for subjects who reject
visible scars, as well as patients that resolutely refuse to
undergo an invasive surgical procedure.
3. Main features: the main feature of the Silhouette sutures,
apart from the strong traction exerted by the cones, is their
ability to stimulate the growth of fibrous tissue around
and inside the hollow resorbent cones; in this way, an effi-
cient suspensive effect is obtained as well as a natural
antiaging system based on the production of new collagen
fibers.
Once the cones are reabsorbed (within the first year), the per-
manence of the polypropylene thread will allow for longer-
lasting results; their actual life span will depend on the
type of skin as well as on the number of the positioned
threads (on average, at least four threads for each side of
the face and two for each side of the neck) as well as on the
patient’s lifestyle (exposure to the sun, smoking, diet, etc.)
4. Is it possible to maintain the results for longer? If you
want to optimize the results and prolong the effects, it is
possible to re-tension the threads again 1 or more years
after the original procedure, as well as positioning other
sutures on an outpatient basis, using the original
incision.
5. Is it an outpatient procedure? The Silhouette Lift is
considered an outpatient surgical procedure that can be
performed under local anesthesia; it requires 45/60 min
and has to be performed under sterile conditions in a suit-
able and protected clinical center (outpatient clinic or
other authorized centers); an anxiolytic premedication or
a potential sedation is available at the discretion of the
surgeon or upon the patients’ request.
Surgical aftereffects
As the Silhouette Lift is minimally invasive, it is normally
considered a safe procedure, but as in the case of any sur-
gical activity, a few complications may occasionally occur.
I am definitely aware that:
1. Any incision heals through the formation of scar tis-
sue; the incision lines can be evident at the beginning
of the postoperative period, even if the greatest atten-
983
tion will be paid to make these minimally visible;
occasionally, in close proximity to the incision lines, a
hair loss which is almost always transient may occur.
2. Discoloration of the skin may occur, and the operative
site may present swelling, lasting for a few days, a
couple of weeks, or for a longer period.
3. After the procedure, the patient may experience tender-
ness, tension, and discomfort, usually of a mild degree.
These inconveniences may involve the temporal region,
the face, or the neck; they usually disappear in a few weeks.
In case of particularly long duration or intensity, it may be
necessary to cut the knot that is tensioning the sutures.
4. Hematomas and bruises may appear, lasting for 1 week
or longer.
5. Scattered zones of numbness, hypersensitivity, and
palpable irregularities may appear postoperatively in
the treated area; these may persist for an indefinite
period of time.
6. An infection may ensue, and this can delay healing
and cause a slower cicatrization of the tissues, just as
allergic and/or adverse reactions to one of the sub-
stances employed may occur.
7. Advancement of the aging process and further tissue
sagging, with the appearance of new wrinkles and
grooves, will probably progressively recur in the years
after the procedure.
8. I acknowledge that during the procedure, unexpected
events may occur, thus requiring additional or differ-
ent surgery to that aforementioned.
I hereby authorize and request that the surgeon, his
assistants, or the persons in attendance that he has
selected to carry out any kind of procedure that he may
deem necessary or beneficial including, but not limited
to, the performance of services involving pathology
and radiology.
9. I consent to be photographed and filmed for scientific
reasons; I understand that this material is the property
of the abovementioned surgeon and may be published
in scientific journals or shown for scientific reasons
(during teaching activities and medical meetings).
Informed Consent to the Silhouette Lift
The undersigned……………………..
born in………………….. on………………………….
I hereby authorize the surgeon……………….
to perform the Silhouette Lift Procedure on me
:……..………………………………
I hereby declare that I have read the Informative Form which
is part of the Informed Consent and fully understood this
984
in all its parts and that I have had a reasonable amount of
time to meditate and discuss it with the surgeon.
I declare that the possibility of alternative treatments and the
event of renouncing from surgery has been discussed and
fully evaluated with the surgeon.
Date and signature
Acknowledgments The author is grateful to M. Gamboa M.D., for his
contribution to the technical development of neck suspension; to
L.O. Vasconez M.D., M. Del Bene M.D., and P.C. Parodi M.D., for
their support provided for the static suspension in patients with late
consequences of facial nerve palsy; to J. De Benito M.D., for studying
and supplying the “pearls” for an optimal technical performance; and to
Y. Saban, for his support regarding anatomical studies on cadavers.
References
1. Mansberger AR, Jennings ER, Smith EP, Yeager GH (1951) A new
type pull-out wire for tendon surgery: A preliminary report. Bull
Sch Med Md 36:119
2. Alcamo JH (1964) Surgical suture. US Patent 3,123,077, 1964
3. McKenzie AR (1967) An experimental multiple barbed suture for
the long flexor tendons of the palm and fingers. J Bone Joint Surg
Br 49:440
4. Salasche SJ, Jarchow R, Feldman BD et al (1987) The suspension
suture. J Dermatol Surg Oncol 13(9):973–978
5. Usher FC, Allen JE, Crosthwait RW et al (1962) Polypropylene
monofilament: a new biologically inert suture for closing contami-
nated wounds. JAMA 179:136
6. Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze G
(2000) Removal of facial soft tissue ptosis with special threads.
Dermatol Surg 28:367–371
F.R. Perego
7. Sulamanidze MA, Shiffman MA, Paikidze TG, Sulamanidze GM,
Gavasheli LG (2001) Facial lifting with APTOS threads. Int J
Cosmet Surg Aesthet Dermatol 4:275–281
8. Sulamanidze MA, Paikidze TG, Sulamanidze GM et al (2005)
Facial lifting with “Aptos” threads: featherlift. Otolaryngol Clin
North Am 38:1109
9. Sasaki GH, Cohen AT (2002) Meloplication of the malar fat pads
by percutaneous cable-suture technique for midface rejuvenation;
outcome study (392 casus. 6 years experience). Plast Reconstr Surg
110:635–654
10. Wu WTL (2003) Facial rejuvenation using APTOS and WAPTOS
(the WOFFLES LIFT): a novel approach. 13th international con-
gress of the international confederation of plastic and reconstruc-
tive surgery (IPRAS), Sydney, 10–14 September 2003
11. Isse NG (2005) Elevating the midface with barbed polypropylene
sutures. Aesthet Surg J 25:301
12. Malcolm P (2006) Using barbed sutures in open/subperiosteal mid-
face lifting. Aesthet Surg J 26:725–732
13. Gamboa GM, Vasconez LO (2009) Suture suspension technique for
midface and neck rejuvenation. Ann Plast Surg 62:478–481
14. Bisacia E, Kandry R, Saap L, Rogachefsky A, Scarborough D
(2009) A novel specialized suture and inserting device for the
resuspension of ptotic facial tissues: early result. Dermatol Surg
35:645–650
15. Isse N (2008) Silhouette sutures for treatment of facial aging: facial
rejuvenation. Remodelling, and facial tissue support. Clin Plast
Surg 35(4):481–486
16. Michaelidou M, Tzou CH, Gerber H, Stüssi E, Mittlböck M, Frey
M (2009) The combination of muscle transposition and static pro-
cedures for reconstruction in the paralyzed face of the patient with
limited life expectancy or who is not a candidade for free muscle
transfer. Plast Reconstr Surg 123(1):121–129
17. Ozaki M, Takushima A, Momosawa A, Kurita M, Harii K (2008)
Temporary suspension of acute facial paralysis using the S-S Cable
Suture (Medical U&A, Tokyo, Japan). Ann Plast Surg 61(1):
61–67
 3D Facial Volumization with Anatomic
Alloplastic Implants
Edward O. Terino
1 The Power of Beauty
There is an ancestral need for beauty in mankind. Evidence
of this quest goes back to prehistoric times: tattoos, rings
through the ears and nose, the wrapping of Oriental women’s
feet; many other tribal and cultural customs were for the pur-
pose of enhancing beauty. More contemporary and sophisti-
cated methods are obvious – hair dying, cosmetics and
makeup techniques, as well as the use of physical adorn-
ments such as jewelry, earrings, clothing, and hairstyles in
thousands of forms. All of these are for the single purpose of
improving the appearance of creating beauty.
“Why?” we say. Improved self-image through improved
appearance has proven to people over the centuries to be a
means of (1) better realizing ourselves as human beings, (2)
influencing other individuals, (3) communicating better in
our lives and, finally (4) a means to gain power, if you will,
and (5) to obtain things.
This urgent need threads its way through history as a
mechanism for man to increase his level of acceptance.
In other words, feeling good about ourselves and our
appearance assists our goal for optimum wellness and
survival.
A more attractive and beautiful individual always appears
to have a better chance to ascend the social scale; to improve
in his or her own fields of endeavor and perhaps even more
desirable, to reach new emotional and sentimental heights.
Every man and woman searches for absolute truth through
many pathways.
However, beauty is almost always found in any human
endeavor as a constant, and therefore, as an important infra-
structure for the personal growth of the individual.
E.O. Terino, MD
Plastic Surgery Institute of Southern California,
Thousand Oaks, CA, USA
Private Practice, Agoura Hills, CA, USA
e-mail: terino@pixelgate.net
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_69
In his quest for optimum survival, man sometimes lives
mechanically as a machine with a set routine or he aspires to
be human with complex inspirations for living. In either
case, beauty and attractiveness are efficient means to help
select the most appropriate option. This ability to exert
options is evident in our selection of clothes, accessories,
hairdos, cosmetics, and jewels.
When none of these produce adequate satisfaction, we
may turn to a more transcendental solution in the hands of
the aesthetic plastic surgeon. This, then, often becomes
another manifestation for the search for a balance, which
will create the capacity to experience life to its fullest extent.
Aesthetic plastic surgery is the surgery of harmony, good
taste, and a beautiful attitude. We first train our hands in the
practice of general surgery. As plastic surgeons, we then
must further refine our talents and techniques in order to
combine our artistic with our scientific judgment. In this
way, we learn to evaluate the body’s tissue capabilities to
resist the surgical action of being “sculptured,” i.e., perma-
nently and structurally changed to possess aesthetic balance
and symmetry perceived as beauty.
But, this aesthetic perception can only be acquired by
intense acts of seeing, listening, feeling, and studying. This
is why plastic surgery is the surgery of experience, wisdom
and personal realization.
Aesthetic plastic surgery is also an art form. It searches
for a way to create, or to recreate forms that will inspire the
innermost vibrations of the soul, which we ultimately experi-
ence as happiness.
Aesthetic plastic surgery requires a study of life, man, art,
and the intimate knowledge of how these elements intensely
interrelate to affect our everyday living – personally, roman-
tically, and in our business.
It is important that all plastic surgeons be able to judge
each patient as an individual. If a patient is trying to regain
beauty, it is necessary to know what beauty represents for
that individual. To understand the patient’s emotional needs,
the aesthetic surgeon needs to spend a great deal of time
focusing on psychological communications, evaluations,
985
986
considerations, and communications. This is the only path
by which plastic surgeons shall be able to understand their
patients and the complexities or simplicities of their desires.
Only then can they determine whether the candidate is suit-
able for the emotionally charged alterations from aesthetic
surgery. Therefore, by doing the steps of this formula, the
plastic surgeon shall be able to integrate into his surgery all
of the critical messages that flow from art, science, and
philosophy.
This search for beauty is not restricted to Southern
California or even the United States. It is easy to observe that
this need exists for all mankind throughout all countries and
cultures. Many plastic surgeons have developed their recon-
structive and aesthetic talents throughout the world in various
voluntary programs such as Project Hope, Interplast, Care
Medico, Project Concern, and at many independent mission-
ary hospitals such as the Hospital Albert Schweitzer in Haiti.
Communication creates understanding. The goal, there-
fore, is to share these philosophic thoughts with patients
prior to their consultations. Hopefully, they can help us as
surgeons to understand each other and thereby create a mutu-
ally satisfying aesthetic, as well as surgical experience for
both of us.
2 A Brief History of Aesthetic Facial
Surgery
It was in the late 1800s and early 1900s that patients in good
financial standing and who also perhaps held some promi-
nence in professions like politics, business, or entertainment
were requesting help from plastic surgeons for their facial
aging changes. This is the period when an operation called
rhytidectomy was first conceived and executed. The major
players who pioneered this procedure where relatively few in
number and included J. Dieffenbach, Joseph F. Kolle,
E. Hollander, R. Passot, A Bettman, and others [1]. Even at
that early time, they were engaged in an egocentric competi-
tion regarding who conceived of the idea first and who pri-
marily executed it.
The “face lift” technique in those days was quite simple.
Ellipses of skin on the face were removed and closed with
sutures in an attempt to tighten the skin to “remove wrin-
kles.” The procedures then progressed to lifting and under-
mining small regional areas of the face and pulling the
resulting skin flaps tight followed by excision of the excess
and suture closure.
This operation, therefore, got off to a bad start because
from a present-day vantage point, it can readily be under-
stood that removing wrinkles, with an operation called rhyt-
idectomy, a synonym chosen from the Greek (“rhytids”) was
impossible by using the above-mentioned techniques. It is
now recognized that “wrinkles” represent degeneration of
E.O. Terino
collagen and other support elements in the epidermis/dermis
resulting from age and radiation sun damage that cannot be
removed by pulling skin tight.
The early rhytidectomy procedures had very limited and
short-lived results due to tension of the skin closure, which
resulted as well in highly unattractive and permanent scars.
Moreover, plastic surgeons and associated colleagues in
the field of dermatology are still struggling with advanced
technologies, which attempt to remove wrinkles and mostly
fail, especially when the wrinkles are deep.
The next major advance came in the 1970s when Tord
Skoog conceived the idea of tightening the infrastructure of
subcutaneous facial fascia, i.e., the submusculo aponeurotic
system described by Mitz and Peyronie [2, 3]. This started a
new era of cosmetic facial surgery during the 1970s, 1980s,
and 1990s, resulting in extensive anatomic facial dissections
and manipulations of muscular and fascial planes designed
to reposition and restore the tension and tightness of underly-
ing layers in a vertical direction. This concept was promoted
as the ideal reconstruction for sagging fat and other elements
in the aging face [4, 5].
These modern and sophisticated procedures proved to
have their severe limitations as well. Not only does the elas-
tic nature of the layers sutured one to another under tension
relapse and stretch in a limited time (which is variable
depending on the genetics and tissue characteristics of the
patient), but these procedures are also two-dimensional in
nature and do not restore or mimic the more ample aesthetic
soft tissues required for desirable, more youthful facial
contours.
In our present culture, individuals endowed with an excel-
lent skeletal framework underlying the soft tissue layers of
the malar–midface and chin–jawline have become the hall-
mark of beauty. Therefore, by definition, three-dimensional
aesthetic structuring of the face must be the final ultimate
goal in facial aesthetic surgery.
An artist is one who perceives natural beauty and devel-
ops techniques to imitate it. Artistic perception varies from
artist to artist, patient to patient, and surgeon to surgeon.
However, there are common denominators in facial form and
structure, which are perceived by the majority and dictate
what is ultimately highly desirable in our present historic
time period.
Even the casual observer easily notices the progressive
shrinking atrophic quality of soft tissue substance in faces,
both male and female. This quality has often been negatively
described as an older and tired look of aging rather than the
beauty of youthful maturity.
This deterioration of the more ample and youthful quality of
a face, at the least, may be observed as early as the mid-to-late
20s and rapidly proceeds into the 30s and early 40s as well.
It is also commonly acknowledged that in individuals
possessed with an excellent underlying skeletal foundation
3D Facial Volumization with Anatomic Alloplastic Implants
that as aging progresses, the soft tissues shrink and the bony
prominences show more definition in the face. For many,
this definition produces an enhancement of beauty while in
others it unattractively defines the overlying soft tissue atro-
phy. This, then, can frequently produce a negative effect,
which subtracts from the appearance of earlier youthful
beauty. Therefore, soft tissue substance as well as skeletal
structure constitute the basic common denominators, which
determine the three-dimensional aesthetic form and shape
of faces, which is culturally recognized as attractive or
beautiful.
3 Theme of This Chapter
The theme of this chapter is to describe and illustrate con-
temporary technology that uses alloplastic implants to aug-
ment the facial skeleton throughout the face and proves the
thesis that “Three dimensional facial form and shape using
alloplastic facial augmentation techniques is essential for
creating optimum aesthetic beauty and is the “final chapter”
in the development of cosmetic facial surgery.”
4 Historical Background
of Three-Dimensional Alloplastic
Volumization of Faces
Recently, the public demand and expectations for aesthetic
facial surgery in both males and females has increased dra-
matically. This has challenged surgeons and scientists to
develop more natural and longer lasting enhancements that
are safe, ethical, and scientifically tested. Today’s facial aug-
mentation technology far exceeds earlier fads such as the
well-publicized 1970’s silicone injections to accentuate
“cheekbones” and facial contours, which resulted in horrific
complications. Moreover, its abilities for permanent and pre-
cise aesthetic alterations transcends any other methods,
including today’s semipermanent injectable fillers.
Among the first materials used successfully were nonre-
active metals such as stainless steel and Vitallium. The past
four decades of scientific research in solid-state synthesis,
material sciences and facial contour aesthetic theory has
yielded a new applied clinical science with an armamentar-
ium of tools, which have reliable and reproducible surgical
techniques.
Recent history has seen the introduction of silicone rub-
ber (Silastic), Proplast I & II, Mersilene, Teflon, Dacron,
Gore-Tex, acrylic, methymethacrylate, polyethylene, and
hydroxyapatite. This chapter will endeavor to describe the
facial architectural concepts and applied surgical techniques
that are employed by Dr. Edward O. Terino in the 1970s to
alloplastically augment the entire aesthetic facial contour.
987
The author, Edward O. Terino, is widely recognized for
his unique and bold contribution to the development of
reproducible and more anatomically precise alloplastic
implants for facial rejuvenation [6]. This was a time period
when the surgical community was still greatly influenced
and biased toward the sole use of autologous craniofacial
reconstruction techniques pioneered by Dr. Paul Tessier [7].
At the turn of century, the search for safer and more dura-
ble alloplastic materials grew out of necessity due to a need to
camouflage contour defects secondary to congenital (e.g.,
cleft deformities) or traumatically acquired (e.g., modern
warfare, automobile accidents, etc.) facial skeletal
deformities.
More surprisingly, alloplastic materials have been used
for centuries earlier in cosmetic and reconstructive surgery.
The roots of this science find themselves first described in
papyrus documents from ancient Egypt and Greece.
Fascinating ancient anecdotes (before AD 1000) included
the use of sea shells hammered into the jaw to replace miss-
ing teeth (dental implants).
In the twentieth century, chin alloplastic augmentation
was first described in 1948 [8]. Gonzalez-Ulloa is credited to
be among the first surgeons to describe malar augmentation
with alloplastic implants [9]. In the mid-1960s, Ulrich
Hinderer developed unilateral corrective malar silicone
implants [10].
Now we find ourselves in a new era of facial augmenta-
tion that has an exciting and promising future due to an ever-
expanding armatorium. The refined synergism of classical
tissue transfer, injectable fillers, and alloplastic implants por-
tends to define the next decade of advanced facial aesthetic
surgery ultimately leading to the future “promised land” of
true tissue engineering based on intimate knowledge of cell
biology and stem cells.
5 Facial Aesthetics and Contouring
Facial aesthetics, therefore, is paramount in today’s world
where surgical alterations of anatomy to improve attractive-
ness have become a reality rather than a sci-fi fantasy.
The “sculptural” nature of faces has been known by artists
from time immemorial. By sculptural, we are referring to
three-dimensional form. In a face, this encompasses many
integral parts whose volumes and masses interrelate through
their juxtaposition. These by virtue of their relative size and
shape constitute what plastic surgeons now call the aesthetic
facial balance of beauty.
The surgical creation of beauty is the art and science of
perceiving and creating a correct balance of three major
promontories of facial skeletal anatomy. These three funda-
mental facial promontories are the nose, malar–midface, and
jawline regions (Fig. 1).
988
The diminution or enhancement of any one of these three
promontories directly or inversely affects the aesthetic sig-
nificance of the others. In other words, reduction of the nose
gives the illusion of a stronger chin, jawline, and midface
region. Conversely, increasing a chin size makes a nose
appear more proportionate.
Facial balance necessitates working with both the skeletal
foundation and the soft tissues. Facial bone size and shape
determines the structural definition of faces. Our present
society considers such definition attractive or beautiful, both
in youth and even more so during the aging process. The
Brow
Nose
Malar-midface
(cheek)
Mandible
(chin, jawline)
FACIAL ARCHITECTURE
• The major promontories of mass and volume
Fig. 1 Artist’s rendering of facial architecture illustrating major prom-
ontories of mass and volume: the nose, malar–midface, and mandible
jawline
Fig. 2 Anatomic-style implants designed in the 1980s by the author to imitate natural bony and soft tissue contours in malar–midface and pre-
mandible regions
E.O. Terino
shape of the facial skeleton determines the contours of the
overlying soft tissues.
The term facial contouring may be applied to augmenta-
tion of the facial skeleton through the use of Silastic onlay
implants. These implants are placed on the deepest or fourth
plane, the facial skeleton (Fig. 2).
The other three planes defined in facial surgery are the
skin, the subcutaneous fat, and the SMAS. Despite the most
radical, extensive skin and soft tissue tightening or Bi-Planar
and SMAS techniques, facial contour does not significantly
change because these procedures are merely two-dimensional
in nature. They involve merely elevating tissue planes that
are elastic and pulling them tight to attach to underlying and
similarly elastic, stretchable tissues. Whereas, only judicious
alterations of mass and volume carefully placed in different
anatomic regions can produce contour changes and with
dimensions of permanence.
Skeletal augmentation with alloplastic materials gives
plastic surgeons for the first time the ability to aesthetically
sculpture faces in three dimensions with precise and perma-
nent methods.
Therefore, technically, the creation of beauty can be
accomplished through selecting implants of the proper size,
shape, and design, and by controlling their position on the
facial skeleton. Used properly, alloplastic implants can alter
and modify, in either a subtle or dramatic way, the facial
promontories with ease and predictability.
Autologous soft tissue manipulations and injectable
materials add versatility to the armamentarium of the aes-
thetic plastic surgeon. However, in the opinion of the author,
these are significantly non-precise as well as unpredictable
in result and stability. They are, however, useful for “fine
3D Facial Volumization with Anatomic Alloplastic Implants
tuning” soft tissue contours overlying alloplastic augmenta-
tions on the skeleton to improve or correct patient perceived
imperfections and thereby assist in achieving an optimum
degree of patient satisfaction.
In the near future, computer-engineered technology will
be able to determine and manufacture individualized
implants according to precise design, dimensions, and posi-
tioning. Present limitations of surgical technique and implant
types do not always permit unerring accuracy in achieving a
patient’s ideal appearance. However, the superb advantage
that Silastic implants have over other facial skeletal augmen-
tation biomaterials is that the implants are readily exchange-
able should the need or desires arise.
Simple elevations of the soft tissue envelope of the face to
create space for alloplastic implants results in infinitely less
morbidity and complications than the intricate dissection of
the SMAS in and around the neuromusculature of facial
animation.
6 Cultural Variations in Facial Beauty
Throughout history, standards of facial beauty have always
been associated with anatomic contours of facial form.
During some centuries, roundness and fullness of facial form
were the cultural standard of artists while in other time peri-
ods, more defined and dramatic skeletal contours in the mid-
face and jawline region were in vogue.
During the Renaissance, many artists depicted an ideal
female face as heart shaped, and exhibiting weak lower face,
chin, and mandible contours.
Venus De Milo and the Cherubic women, painted by the
artist Peter Paul Rubens, are symbols of ideal feminine faces
and figures of past cultures. Today, standards have dramati-
cally changed.
7 Facial Aesthetics: Contemporary
Ideals
In the new millennium, male images have superhero charac-
teristics. Jawlines, such as those of Captain Marvel,
Superman, the Lone Ranger, Batman (Fig. 3) and others are
commonly seen in fashion magazines, on television, soap
operas, and in the cinema. The images of Kirk Douglas, Eroll
Flynn, and Gregory Peck have been replaced by the jutting
jaws of Mel Gibson, Brad Pitt, Johnny Depp, and a new gen-
eration of other strong masculine faces.
Contemporary standards of female beauty also embody
stronger structural contours. Jawlines that contemporary
females request have more anterior projection, a wider mid-
lateral region, and a stronger posterolateral angle definition.
Malar–midface cheek contours are also strong and defined.
989
Today, ideal female faces must exhibit the Amazonian exotic
facial contours of Wonder Woman (Fig. 4) as typified today by
Angelina Jolie, Cameron Diaz, Rebecca Romijin, and others.
Cosmetic surgery has achieved respectability. A growing
population of upwardly mobile, affluent patients in a younger
age group from 20 to 50 are demanding surgical alternatives
for their inherited facial characteristics. Midfacial and jaw-
line contours are the main focus of their desired changes.
Whereas nasal surgery and chin implants have been well
accepted by plastic surgeons and the public for the last
30–40 years, alterations in additional regions of soft tissue
and skeletal contours of faces are now an increasingly popu-
lar, sought after commodity. The most commonly requested
changes are for stronger, more square, angular jawlines, and
more accented midface and cheek bone contours.
8 Advantages
The advantages of alloplastic augmentation of the facial
skeleton are many.
1. The number one advantage is permanence of shape, vol-
ume, and form. Implant dimensions are precise and
unchangeable because of the solid characteristics of their
material substance.
2. They supplement existing or deficient volume, mass, and
shape in the various natural promontories of the face. The
most important of these are the malar–midface and jaw-
line–premandible regions. The nose is a third major
promontory. Great aesthetic advantage derives from aug-
menting or diminishing its volume. However, alloplastic
augmentation of a nose is still very controversial.
3. Alloplastic materials do not need harvesting operations
on other areas of the body.
4. The operations are brief, mostly 30–45 min.
5. Placement under the periosteum and directly on bone pro-
duces rapid immobilization by collagenous capsular
formation.
6. Depending on the material used, the biologic compatibility
of the host to resist “rejection” and infection is very high.
The author favors silicone rubber because resolution of
surrounding infections can be accomplished in nearly all
cases without the necessity of implant removal. Antibiotics
and drainage procedures will nearly always abolish infec-
tion around such implants as long as they are nonporous.
Porous materials such as Goretex, hydroxyapatite, and
Porex or Medpor, when infected, usually have to be
removed because infectious processes can lodge within the
interstices of these nonsmooth materials and challenge
body defenses. A final and perhaps most desirable major
advantage of alloplastic facial augmentation is easy remov-
990
Fig. 3 Example of contemporary desires of male images
ability, reversibility, and exchangeability. Silicone rubber
implants are very flexible and can be introduced and
removed through small incisions.
9 Disadvantages
The major disadvantages of the use of alloplastic materials
are several:
1. Possibilities of infection, especially with porous materi-
als. These become infiltrated with fibrous ingrowth,
which prevents easy removal.
2. Contour abnormalities of an unattractive or even disfigur-
ing nature when implants do not have the proper shape,
size, and positioning.
3. Possibilities for facial nerve and musculature damage due
to excessive and inappropriate trauma during dissections
to introduce or to remove the implant materials.
E.O. Terino
10 Zonal Anatomy of the Malar
and Premandible Regions
That part of the facial skeleton which, when appropriately
augmented, produces an aesthetic change in the contour of
the cheek and midface is called the “malar space.” To deter-
mine the most aesthetic augmentation to select for that space,
it is useful to perceive the malar region as five distinct ana-
tomic zones (Fig. 5).
Zone 1, the largest area, includes the major portion of the
malar bone and the first third of the zygomatic arch.
Augmentation of this entire zone produces the greatest
volumetric filling of the cheek and also maximizes the
projection of the maxillary eminence (Fig. 6).
Zone 2, the second most important site, overlies the middle
third of the zygomatic arch. Enhancement of this zone
along with zone 1 increases the accentuation of the cheek
bone laterally, giving a broader dimension to the upper
3D Facial Volumization with Anatomic Alloplastic Implants
Fig. 4 Example of contempo-
rary desires of female images
third of the face, thereby creating a high, arched appear-
ance. This change of contour is particularly useful for
individuals with a narrow upper face or a long-face syn-
drome (Fig. 7) When, however, zones 1 and 2 are aug-
mented in excess, an abnormal and unattractive
protruberance may result (Fig. 8).
Zone 3 is the paranasal area, which lies medial to the
infraorbital foramen and nerve. A line drawn vertically
down from the infraorbital foramen marks the medial
extent of the usual dissection for malar augmentation.
This line also represents the lateral border of zone 3.
991
When paranasal augmentation occurs, zone 3 creates a
medial fullness of the face, often in the upper nasola-
bial area, which can be unattractive or can produce a
“chipmunk-cheek” effect. The skin and subcutaneous
tissues are thin in that region; consequently, any
implant placed there must be perfectly sculptured and
tapered. Augmentation of zone 3 is indicated for cer-
tain reconstructive purposes, following trauma or other
heredity deficiencies. Zone 3 along with the entire
lower orbital rim and suborbital region constitute an
important area to augment with an implant to alter the
992 E.O. Terino

Fig. 5 The midface has five distinct anatomic zones

a b c

Fig. 6 Zone 1 malar (4 mm) augmentation in a 37year-old female. Note increase in anterior and posterior projection of the malar eminence, pro-
ducing a prominent high, sharp contour. Preoperative (a, b) and postoperative view (c)

unattractive hollowness of aging or a recessive inferior
orbital rim deficiency (Fig. 9).
Zone 4 overlies the posterior third of the zygomatic arch.
Augmentation in this area is never needed. It would pro-
duce an unnatural appearance. Moreover, dissection here
may be dangerous, because the tissues overlying the bone
are quite adherent, making it very possible to injure the
zygomaticotemporal or orbicularis oculi branches of the
facial nerve, and even the capsule of the temporomandib-
ular joint. Symptoms and deformities have been observed,
which resulted from operations in this area.
Zone 5, the submalar zone or “submalar triangle,” is
bounded posteriorly by the masseter muscle tendinous
origins, and anteriorly by the canine fossa region of the
3D Facial Volumization with Anatomic Alloplastic Implants 993

Fig. 7 A 33year-old female with long-face syndrome who benefited by 1 and SM was used and a 6 mm extended anatomic chin implant. Left:
camouflage augmentation rather than midface osteotomy or sliding Preoperative and Right: postoperative views
genioplasty. A 5 mm midface malar–submalar implant placed in zones
994 E.O. Terino

a b

c d

Fig. 8 A 42-year-old female who underwent augmentation with tradi-
tional small high-profile implants. The patient is left with a skeletal
appearance. Contemporary Terino implants are wider and have less pro-
jection. Top: (a) Preoperative view: malar implants, wrong size, shape,
and position. (b) Postoperative view: correction of skeletal appearance
with larger anatomic malar shell implants in zones 1 and SM. Bottom:
(c) Preoperative view: malar implants, wrong size, shape, and position.
(d) Postoperative view: correction of skeletal appearance with larger
anatomic malar shell implants in zones 1 and SM
3D Facial Volumization with Anatomic Alloplastic Implants
c d
Fig. 9 A 35-year-old male, with negative vector, suborbital hollowness
deficiency, facial type 4 aesthetic regional volume deficiency, malar
hyperplasia, and submalar maxillary deficiency (a, c, e). Left view, pre-
operative, postoperative views taken 1 year following tear trough (size
maxilla. The superior boundary of zone 5 is the inferior
bony margin of the malar eminence, which constitutes
the first two-thirds of the zygomatic arch. The medial
extent of the submalar space ends at the lateral border of
the nasolabial mound and sulcus. Its anterior limit is
bounded by the inferomedial portion of the roof of the
entire malar space. It contains the overlying facial mus-
culature, fat, skin, and subcutaneum of the midface
region. The inferior border is the selected lower limit of
the natural dissection plane that separates the masseter
from the overlying facial musculature. To create midface
fullness, augmentation within the sulcus that this lower
limit dissection creates is required.
Natural aging, as well as inherited tendencies, causes
soft tissue deficiency to develop in the inframalar midface
region. This is accentuated by the superior overhanging
prominence of the solid maxillary malar eminence, as well
995
a b
e f
large, 4 mm) implant placed in suborbital zones 3 and 5 (b, d, f). The
arrow points to the sub orbital hollow (a, c, e) before filling it with an
implant (b, d, f)
as by the medial− and downward sagging of the nasolabial
mound. The result is a midface sulcus, or depression, that
overlies this submalar zone. In many individuals, midface
atrophy creates a tired, drawn, and haggard appearance as
early as the third and fourth decades of life. Augmentation
within the submalar zone, beneath the soft tissue sulcus,
can bring back a fuller, rounder, and more youthful contour
(Fig. 10).
A solid implant in the submalar zone recreates the
patient’s maxillary architecture by effectively adding to the
vertical length of the malar bone down from the lateral can-
thal region into the mid cheek. The all-encompassing “malar
shell” implant, which the author of this article developed
over the past 25 years, goes beyond the submalar concept by
augmenting both the entire malar bone and submalar region
into a completely united full, round cheek.
By understanding the five zones of the facial anatomy and
their interrelationships, the surgeon can vary cheek shapes to
996 E.O. Terino

Fig. 10 Top: A 67-year-old female, with emaciated appearance, aging tion with Terino malar shell, extra large 5 mm. Bottom: A 43-year-old
facial atrophy, and extreme laxity of the facial skin. The patient desired female, with extreme facial type 3 submalar atrophy and prominent
only augmentation of the malar midface. Postoperative view taken malar bones. Postoperative view taken 6 months following submalar
1 year following malar midface submalar zone 5 and zone 1 augmenta- zone 5 augmentation, with large Terino malar shells of 4 mm
3D Facial Volumization with Anatomic Alloplastic Implants
accommodate individual patients. Success is determined by
appropriate choice of size and shape implant and knowledge
of which zone or zones to augment.
11 Regional Midfacial Volume
Deficiencies
A useful tool to assist the surgeon in determining which ele-
ments are necessary to achieve facial balance in any specific
patient is the appreciation of malar–midface zonal deficien-
cies. Although the number of variations in facial size, shape
and contour are infinite, there are several common midfacial
types that can easily be identified for the purpose of deter-
mining specific implant sizes and placement positioning.
Several of these will be described.
A facial type I deficiency consists of a relative contour
weakness in the upper segment of the malar–midface. It
encompasses zones 1 and 2 over the malar bone and the
medial third of the zygmatic arch. This represents either a
bony or soft tissue deficiency, or both. Augmentation in these
zones creates upper cheek definition that simulates both
bony and soft tissue contour (Fig. 11). When a large implant
is used to augment zone 2 as well as zone 1, the upper mid-
face becomes broader. This shortens the appearance of a long
and narrow face (Fig. 12).
A type 2 facial regional aesthetic deficiency consists of a
relative decreased volume in the submalar (SM5) zone. An
implant placed in this location produces volume filling that
also imitates both bone and soft tissues. Utilization of a large
malar shell over the inferior aspect of the malar bone in zone
1 and extending down into the submalar space creates the
illusion of a round, full, apple-cheek (Fig. 13). The fat atro-
phy that occurs in the aging face is well corrected by implants
that are placed into the submalar 5 anatomic region. This
type 2 midface has adequate malar bone prominence but
is specifically deficient in submalar soft tissue volume. This
can create an older, tired, haggard look (Fig. 14).
A type 3 regional volume deficiency consists of a strong
malar–zygomatic super structure accompanied by an
extremely deficient submalar infrastructure. When this condi-
tion is accompanied by thin skin and subcutaneum, the
appearance is one of emaciation atrophy and even sickness.
Fortunately, unless a person has actual physical debility, this
facial type is uncommon in the general population. Correction
requires a generous submalar augmentation with a large sur-
face area midface shell that may have a projection thickness
of 5–7 mm. Since the submalar zone ends just lateral to the
nasolabial smile mound, volume filling of this space
997
de-emphasizes the appearance of the nasolabial mound and
corrects the sunken or flat appearance in the midface to restore
a more youthful and full appearance to the face (Fig. 15).
A type 4 face consists of extreme volume deficiency
throughout the entire anterior maxillary region. This includes
malar zones 1 and 2 and the SM5 region, and also includes
the entire orbital and paranasal zone 3 area. This seems to be
more common in men than in women (Fig. 16). It is identi-
fied by a “flat” face, or “dish” face appearance. It has been
described as the “polar bear” syndrome because of the defi-
ciency recession of the inferior orbital rim, which contributes
to a proptotic, bulging appearance of the ocular globe. It is
also called a “negative vector” bony suborbital condition
when the rim is significantly recessed from the eyeball.
Alloplastic augmentation can improve mild to moderate
premaxillary deficiency to produce significant aesthetic
changes. There are several implant designs and sizes of sili-
cone rubber implants, which have been used successfully
over the years to alter nasojugal and premaxillary bony defi-
ciency of the inferior orbital rim. This hereditary condition
may be associated with a downward or vertical descent of the
lower eyelid causing sclera show.
Significant improvement in this type 4 aesthetic imbal-
ance occurs by placement of a comprehensive shell implant,
or more specifically, suborbital malar extended implants,
which contribute volume in all of these midface zones
including the infraorbital region. This implant also adds sup-
port to the lower eyelid and elevates it to a more attractive
horizontal position (Fig. 17).
Lateral canthopexy techniques are often necessary to cor-
rect the descent of the lower eyelid, which is common with this
facial type and to prevent its worsening after malar surgery.
This represents both an aesthetic and a functional correction.
A type 5 aesthetic regional deficiency represents a spe-
cific weakness of skeletal structure in the inferior orbital and
medial tear trough region. This contributes to a tired, hollow
appearance around the eyes, which occurs following the
deflation atrophy of the periorbital tissues with aging.
A uniquely designed suborbital tear trough implant devel-
oped by the author in 1988, extends from the medial canthus
into the lateral orbital rim. It considerably improves this
appearance (Fig. 18) [11]. Autogenous tissue transplants of
fat, muscle, galea, and temporalis fascia placed into this area
are also successful, but their potential persistence with visi-
ble contour complications has made them controversial. Fat
grafting along the inferior orbital rim was considered by
some to be advantageous, but has been abandoned by most.
In general, the author’s experience is that all autolo-
gous soft tissue grafting manifests unpredictable shrink-
998 E.O. Terino

Fig. 11 Two examples of type 1 faces with relative malar deficiency. Postoperative views show attractive malar–midface contour from zone 1,2
malar volume enhancement
3D Facial Volumization with Anatomic Alloplastic Implants 999

Fig. 12 Augmentation into zone 2, as well as zone 1 widens the upper midface aesthetic segment. Patient with type 1 malar–midface facial deficiency.
Left views: Preoperative, and Right views: postoperative views, demonstrating upper midface widening. Both patients demonstrate this
1000
Fig. 13 Fat atrophy occurs universally with aging faces. This can pro-
duce a sunken, tired, older look. When there is adequate malar bone
prominence in a type 2 or type 3 face, a large malar shell placed in
the submalar region restores a youthful fullness to the face. Top: A
32-year-old female with hereditary midface submalar deficiency. Left:
E.O. Terino
preoperative, right: is 1 year postoperative using Terino extra large
malar shell placed in submalar zone 5. Bottom: A 50-year-old female
with aging midfacial atrophy. Left: preoperative, right: is 1 year post-
operative following placement of Terino extra large malar shell placed
in submalar zone 5
3D Facial Volumization with Anatomic Alloplastic Implants 1001

Fig. 14 A type 2 regional aesthetic deficiency is characterized by a cheek and improves a tired, haggard, emaciated appearance. Left views:
decreased volume in submalar zone SM 5. Utilization of a large malar Preoperative, and right views: 1 year postoperative
shell into the submalar space creates the illusion of a round, full apple
1002 E.O. Terino

Fig. 15 Submalar atrophy in an aging face produces a drawn, tired, demonstrate the benefits of a large submalar alloplastic shell implant in
emaciated appearance. This 59-year-old female and 61-year-old male restoring youthful fullness to the aging face
3D Facial Volumization with Anatomic Alloplastic Implants
Type IV aesthetic
deficiency
combined volume
deficiency
(malar hypoplasia plus
submalar deficiency)
Correction:
jumbo malar shell implant
or combined shell implant
Fig. 16 Before and after pictures of a patient with a type 4 face demonstrating the improvement of an extreme volume deficiency of the entire
maxilla using a comprehensive maxillary shell. This helps to correct a flat or “dish-face” appearance
age and may produce irregularities or result in negligible
improvement.
Over the past 5 years, there has been strong interest in a
subperiosteal elevation of all soft tissue layers from the
maxilla followed by a suspension of them in an upward
direction to provide greater volume filling in the inferior
orbital rim area. This midface suspension can be accompa-
nied by inferior orbital fat rearrangement over the inferior
orbital rim. When this is done, the origins of the orbicularis
muscle are severed in the medial tear trough area and the
arcus marginalis and underlying SOOF tissues are dis-
rupted along the entire orbital rim to create a space for the
intraorbital fat to be transposed and sutured into (Figs. 19
and 20) [12].
Subperiosteal midfacial suspension alone without the
addition of alloplastic implants is a technique, which is still
new enough to require the test of time to evaluate long-term
persistence of volume correction and three-dimensional
improvement of the suborbital hollow appearance and
malar–submalar shape.
1003
A type 6 midface deficiency exists in the perinasal pre-
maxillary region. Volume deficiency or the appearance of
retrusiveness in this aspect of the skeleton is common in cer-
tain ethnic groups, especially Asians and Western Indians in
the Americas. It also exists as a congenital hereditary trait,
which can be mild or severe and which may require compli-
cated orthognathic surgery using maxillary LeForte relation-
ships. Although other materials such as alloderm, autologous
fat, goretex, collagen, and other injectibles are used in the
nasolabial and perialar sulcus, these materials have only
resulted in temporary augmentations. Alloplastic augmen-
tation is permanent. Type 6 peripyriform and premaxillary
volume deficiencies are common. They are frequently over-
looked by aesthetic surgeons. They are usually of lesser
magnitude than the greater volume/mass interrelationships
of the malar–midface, jawline, and nose. Therefore, they do
not command as much attention during an initial aesthetic
facial contour consultation unless the patients are focused
on their deficiency themselves and request treatment by the
surgeon (Fig. 21).
1004
Fig. 17 A comprehensive suborbital malar extended implant contributes volume throughout the entire infraorbital and malar region. This also
adds support to the lower eyelid to elevate it to a more attractive horizontal position
12 Chin–Jawline Augmentation
Historically, a masculine image has been characterized by
qualities of strength, courage, boldness, and aggressiveness.
Masculine images that impress us since youth include those
of presidents, kings, generals, and other manly figures. The
American Indian warrior, the Eskimo or Zulu tribesman, the
Tartar barbarian, the more modem soldiers of World War I
and II, cowboys, policemen, and comic strip super heroes all
represent common images in our society, which contributes
to the concept of “totally male.”
The increasing popularity of cosmetic surgery has
resulted in increasing demands on the part of men as well.
In 1970, an average cosmetic surgery practice contained
approximately 1 % male patients. Currently, men comprise
at least 20 % and perhaps 30 % of an aesthetic surgery prac-
tice. Their greatest desires are to attain the masculine ideal
described above.
E.O. Terino
Today’s men emulate the lean, athletic, and muscular con-
figuration typified by the Greco-Roman statues of the ancient
world. Therefore, liposuction currently leads the list of aes-
thetic operative procedures performed on men (and also
women). Unwanted fat deposits are eliminated from the male
torso with relative ease.
There is also growing interest in altering the male face.
Not only are men choosing to tighten the lax aging tissues of
the face about the eyes and jawline, but they are now enthu-
siastically eliminating hereditary bulkiness of the neck and/
or improving profile definition by nasal contouring and man-
dible–chin alterations.
Traditional nasal contour changes and chin augmenta-
tions have been dramatically modified by newer and more
progressive facial contouring with alloplastic implants.
Present images of masculine facial structure, which are being
sought by today’s male patients derive in part from the 1940s
and 1950s comic strip heroes. Captain Marvel, Superman,
Green Lantern, the Lone Ranger, Batman, and dozens of
3D Facial Volumization with Anatomic Alloplastic Implants 1005

Fig. 18 The use of a uniquely designed suborbital malar implant fat muscle, etc., placed into this area are also successful but their perma-
extending from the medial canthus to beyond the lateral orbital rim con- nence is controversial. Both patients demonstrate successful improve-
siderably improves a type 5 deficiency. Autogenous tissue transplants of ment of the suborbital hollow, tired look using this implant (arrows)

Extent of midface
subperiosteal space
dissection

Masseter m.

Buccal fat

Fig. 19 A subperiosteal upper and midface suspension, especially in the presence of an underlying malar–midface implant, will provide greater
volume filling in the inferior orbital rim and malar region
1006 E.O. Terino

Fig. 20 Here are three examples, before and after

surgery, of patients who had subperiosteal upper and
mid face suspension with improvement in midface
contour and suborbital hollowness treated by fat
transposition
3D Facial Volumization with Anatomic Alloplastic Implants
Fig. 21 (a) A peri-pyriform implant is a successful implant design that
can improve premaxillary retrusion volume contour deformities. (b)
Example of two patients in whom premaxillary retrusive contour defor-
others possessed jutting jawlines, massive cheek bones, and
straight, strong nasal profiles (Fig. 22). These masculine
characteristics assisted greatly in the success of such promi-
nent actors as Kirk Douglas, Gregory Peck, Charlton Heston,
and Errol Flynn. Contemporary images in the 1970s and
1980s include He-Man, Master of the Universe and GI Joe,
along with a revival of Superman, Dick Tracy, and others.
Newer movie stars who have a similar appeal are Arnold
Schwartzenegger, Robert Redford, Tom Selleck, Mel Gibson,
and Clint Eastwood, and most recently, Brad Pitt, Tom
Cruise, Johnny Depp, and Jude Law.
Over the last two decades, there has also been an increas-
ing emphasis and attention on male adornment. Mother
Nature has delegated the male of any species to be the most
colorful, by virtue of both genetic endowment and behav-
ioral manifestation. Society further glorifies the male image
through high-fashion wardrobes, hairstyles, and accessories,
which today include even jewelry through the ear lobes,
nose, and other more private anatomical parts.
1007
mities were corrected using a peri-pyriform premaxillary contemporary
design implant. Preoperative photos are on the left
Within this liberal climate, men are paying more attention
to their bodies and faces. Today’s modern health and fitness
movement has created a new era of athletic endeavor, which
again, emulates the ideal Greco-Roman image. Face lifts for
males and other forms of altering countenance are becoming
popular even in younger men. Nasal contouring and chin
implantation have traditionally been acceptable aesthetic
procedures for men over the past 10–20 years. Now, how-
ever, males are adventuring into facial and jawline changes.
Their goal: A squarer, more angular, sharper, and stronger
facial appearance.
13 Zonal Anatomy
of the Premandible Space
Techniques for chin augmentation have been amplified by
extending the shape and size of the traditional, centrally
placed implant to provide more lateral and posterior alteration
1008
Fig. 22 Example of contemporary ideal male facial skeletal contours
of the chin contour. Oval chin implants have traditionally
been placed between the mental foramina. Implants placed
only into this central segment often produce an abnormal and
unattractive, round, central protuberance (Fig. 23). Moreover,
displacement of the origins of the mentalis muscle by tradi-
tional chin implant surgery may permit a downward disloca-
tion of the overlying soft tissue mound and musculature,
thereby creating a “witch’s chin” or “drooping chin” defor-
mity (Fig. 24). This is particularly accentuated in a patient
who possesses an inherited round, globular, and protuberant
central soft tissue chin mound. It becomes even more unde-
sirable aesthetically if, in the process of aging, he or she
develops an adjacent lateral soft tissue sulcus between the
central chin mound and the sagging, more lateral jowl ele-
ments. This sulcus is known as the “marionette groove” or
the “anterior mandibular sulcus.”
To achieve greater success in chin augmentation, “pre-
mandible space” may be perceived. The “premandible space”
is that anatomic region of the lower face, which, when vari-
E.O. Terino
ously augmented, creates significant changes in the shape
and volume of the lower third of the face and jawline. This
region can be configured into four functional anatomic zones
(Fig. 25).
Extending the premandible space laterally into the middle
half of the horizontal ramus, and the region of the oblique
line, enables the surgeon to define a midlateral zone of the
mandible. Augmentation of this zone, in addition to the cen-
tral mentum, creates a chin–jawline contour that is anatomi-
cally natural (Fig. 26). This embodies the principle of the
“extended anatomic contour” implants designed by the
author [13]. Augmentation within the midlateral zone, and
even further into the more posterior part of the mandible,
creates broadening and definition of the mid and posterior
aspects of the jawline (Fig. 27).
At this point in time, many men are requesting significant
jawline changes. These requests are rapidly increasing every
year. They mainly relate to the posterolateral (PL) zone of
the mandible (Fig. 28). This zone includes the posterior one-
3D Facial Volumization with Anatomic Alloplastic Implants
Fig. 23 Traditional chin implants have been placed centrally between the mental foramina. This often produces a nonattractive central abnormal,
rounded protuberance
third of the horizontal ramus extending back from the
oblique line and includes the gonion of the mandible and the
lower 4 cm of the ascending ramus. Its boundaries are as
follows:
1. The floor is the mandible itself
2. The roof is the overlying muscle
3. The superior border is limited by the sigmoid notch of the
mandible
4. The posterior and inferior borders are limited by strong,
fibrofascial insertions of the masseter muscle
1009
These must be completely released to expand the space
around the bony borders of the mandibular angle. This
release is necessary to allow the curved borders of the com-
mercially available angle implants to extend around the infe-
rior and ascending posterior mandible margins to secure
these implants into position (Fig. 29). Avoidance of a trau-
matic dissection when releasing the masseter muscle from
the bone is necessary so that neither the mandibular branch
of the facial nerve (VII), nor the fragile posterior jugular
veins or anterior facial vein and artery are harmed. When
damaged, these vessels can bleed profusely.
1010
Fig. 24 Abnormal contours from traditional central implants can be corrected by using extended anatomic chin implants designed by the author
Lower
Premandible space
4 zones
Fig. 25 There are four anatomic zones within the premandible space
that can be augmented to correct specific regional contours for the
lower esthetic mandibular facial segment
Variable augmentation of the angle can be produced to
produce a strong posterior jawline contour with excellent
angle definition (Fig. 30). Implants are available commer-
cially that either widen this posterolateral segment in a lateral
E.O. Terino
direction, or extend it downward in an inferior direction.
Extending the posterior mandible down creates a less obtuse,
and more acute posterior mandibular angle, which gives the
lower mandibular border more horizontal definition.
The fourth, final, and very important jawline region is the
submandibular (SM) zone. This zone is defined as “that region
in the lower facial jawline/mandible aesthetic segment where
volume–mass alloplastic alterations will produce variable
lengthening of the vertical dimension of the face.” (Fig. 31).
Traditional alloplastic chin implants do not and cannot
increase the vertical height to lengthen the lower third aes-
thetic segment. Osteotomies with interpositional bone graft-
ing with autologous fat transplants techniques are currently
methods chosen by most plastic surgeons to accomplish this
important contour change. For the novice and ordinarily
trained plastic surgeon, orthognatic genioplasties are techni-
cally complicated, imprecise, and have significant complica-
tions (5–10 %), such as nerve damage, asymmetries, and
“step-off” irregularities.
A unique vertical extension implant was developed by the
author in 1986 to wrap around the inferior bony margin of the
mandible and increase the vertical distance from the lower lip
3D Facial Volumization with Anatomic Alloplastic Implants
Fig. 26 An extended anatomic chin implant easily creates a smooth jawline in the Mid-lateral (ML) zone. Also, a vertical extension implant can,
and so on
to the inferior chin (Fig. 32). It extends 4 mm down and proj-
ects 4 mm forward. It also laterally augments the SM zone
(Fig. 33). This implant adds volume to the anterior mandible
segment and to the prejowl sulcus or marionette groove at the
origin of the anterior mandibular ligament. Implants in the sub-
mandibular zone improve or correct a witches chin deformity,
as well as the anterior mandibular prejowl sulcus (Fig. 34).
Just as volume augmentation changes are specific for
each zonal area of the malar–midface middle third facial seg-
ment, contour changes can be differentially produced in the
lower third premandible jawline. The correct choice of
implant size, shape, and positioning when properly selected
are the key steps to achieving specific predictable results.
Nasal contour–volume alterations are frequently
requested. These procedures also contribute greatly to over-
all aesthetic facial balance (Fig. 35). Especially, since they
relate volumetrically to the profile balance of the mandible
chin aesthetic segment.
1011
14 Technical Steps of Alloplastic Facial
Augmentation
14.1 Selection of the Ideal Facial Implant
The anatomic shape of implants is the critical factor in imi-
tating aesthetic facial contours. In practice, when appropriate
implants have been selected, the potential for mobility and
malposition is almost negligible. Ideal implants should be
easily implantable, nonpalpable, readily exchangeable, mal-
leable, conformable, acceptable to the body, resistant to
infection, and easily modifiable by the surgeon (Table 1).
The author has found with a 30-year experience and thou-
sands of implant procedures that silicone rubber is the most
suitable material for alloplastic facial implants (Table 1).
When placed directly on bone, smooth silicone implants
become rapidly fixed and securely surrounded by capsular
fibrosis; because this creates a space well demarcated, they
1012 E.O. Terino

Fig. 27 Alterations of the premandible space or lower third aesthetic improvement from a rhytidectomy and a large anatomic premandible
facial segment are essential in producing a facial balance, which implant to augment the central mentum (CM) and midlateral (ML)
enhances an attractive appearance. This 56-year-old male demonstrates zones
3D Facial Volumization with Anatomic Alloplastic Implants 1013

Fig. 28 Jawline enhancement is frequently requested by men. Top: before and 1 year postoperatively after placement of angle of jaw implant.
Bottom: before and 1 year postoperatively after placement of angle of jaw implant. Malar augmentation was also performed
1014
Fig. 29 Artist’s illustration, demonstrating a 3-cm intraoral incision
just posterior to the molar teeth. A subperiosteal space is created,
disinserting the masseter from the posterior border, and angle of the
can be removed readily and exchanged when necessary or
desirable. On the other hand, porous implants that permit tis-
sue ingrowth such as high-density polyethylene, e.g.,
Medpor, fenestrated implants, and implants with Dacron
backing have a low but consistent, predictable, and clinically
significant incidence of infection [14].
They are also significantly more difficult to exchange or
modify due to bone sequestration and other locally induced
tissue interactions. Perhaps, most pertinent is the recognition
that Medpor is also more likely to extrude when placed under
thinner tissue coverage [15].
By contradistinction, silastic implants can survive the
onset of inflammation and even gross purulence, whereas
infected porous implants may necessitate removal.
The success of recent anatomic facial implants is also, in
large part, due to their conformability to the facial skeleton.
Implants are being produced whose posterior aspects are
accurately molded to the shape and form of the facial skele-
ton. The evolution of implants volumetrically to fit the
dimensions of the face effectively minimizes mobility and
malposition.
A second achievement has been the increased malleability
and compressibility of facial implants, which enable the inser-
tion into smaller apertures. With the currently expanding use
of larger implants, these two qualities have become even more
critical. Often implants of 10–20 square cm need to be placed
onto the malar bone or the mandible of the facial skeleton.
Silicone rubber implants, fabricated into a suitable
medium-grade consistency, make it possible to perform this
procedure with ease. Finally, the ready modifiability of sili-
E.O. Terino
mandible, as well as its anterior horizontal margin and extending up the
ascending ramus
cone implants works in the surgeon’s favor when a formida-
ble barrier is encountered during the operation. Instead of
enforcing a traumatic dissection on an area of anatomy where
nerve damage may be imminent, the surgeon can easily
diminish the implants or alter their configuration with a scal-
pel without affecting the resulting contour.
15 Suggested Operative Techniques
15.1 With Regard to Operative Technique,
the Authors Offer the Following
Suggestions
1. Stay directly on the bone and the periosteum. Placement
of implants directly on bone creates a firm and secure
attachment to the skeleton. Capsular contracture has not
been seen with facial anatomic implants.
2. Be gentle in elevating the soft tissues from the malar and
premandible regions. When there is adequate infiltration
of local anesthetic agents, the tissue planes separate eas-
ily and without need for forceful trauma. Excessive
trauma may produce mental nerve symptoms, transient or
prolonged, but rarely permanent. Paresis or paralysis of
the zygomaticus, the orbicularis oculi, and even the fron-
talis muscle may occur. Such damage is usually tempo-
rary, but in rare cases it can be permanent and has never
occurred in the author’s stories of over 3,500 chin
implants.
3D Facial Volumization with Anatomic Alloplastic Implants 1015

Fig. 30 Jawline enhancement is frequently requested by men. Top: (left) preoperative and (right) 6 months postoperative after placement of angle
of jaw implant. Bottom: (left) preoperative and (right) 1 year postoperative after placement of angle of jaw implant
1016 E.O. Terino

Fig. 31 Submandibular augmentation with a

vertical extension implant creates a longer face.
The patient demonstrates the advantage of
placing the implant in a young woman who has a
severe hereditary lower facial aesthetic segment
deficiency. Postoperative views are 2 years
following the surgery
3D Facial Volumization with Anatomic Alloplastic Implants
Fig. 32 Two patients with alloplastic vertical chin lengthening. Top: A
32-year-old female with zone 1 malar augmentation and vertical chin
extension implant to create a longer face with greater malar definition.
3. Expand the dissection space adequately in either the
malar or the premandible regions to accommodate the
chosen prostheses comfortably. Elevation of the soft tis-
sues into areas adjacent to bone should be done with a
blunt-edged elevator and, again, as gently as possible.
Anatomically contoured implants of adequate size and
shape present very few problems in malposition or mobil-
ity because they fill the space comfortably and hold their
position by virtue of their contoured posterior surface and
their rapid fixation to bone.
4. Minimize bleeding by using both local and general anes-
thesia. A “dry operative field” is essential for accurate
visualization, precise dissection, and proper placement,
the three critical factors in avoiding potential problems
with hematoma, seroma, infection, inaccurate placement,
and nerve damage. Maintenance of the systolic blood
pressure between 90 and 110 provides optimal hemosta-
sis in combination with infiltration of a dilute lidocaine
0.2 % solution containing epinephrine (Adrenalin),
1017
Bottom: A 36-year-old male who had jaw angles and wanted a longer,
stronger anterior mentum
1:800,000. Clonidine, 0.2 mg by mouth, may also be
given immediately preoperatively to stabilize the hemo-
dynamics of the patient’s blood pressure and pulse
(Table 2) (Anesthesia).
16 Technical Elements
The various routes for entering the malar space, including
the submalar region, are as follows: (1) intraoral, (2) lower
blepharoplasty (subcilial), (3) rhytidectomv, (4) zygomatico-
temporal, (5) transcoronal, and (6) transconjunctival. The
intraoral route has been the traditional and most frequent
approach to maxillary malar and midface augmentation. The
authors use an incision that is L shaped with 1 cm limbs,
made through the mucosa only and in a vertically oblique
direction. It is located over the anterior buttress of the max-
illa, just above the canine tooth and approximately 2.5 cm
medial to the orifice of Stensen’s duct.
1018
Lower aesthetic
unit
Submandibular implant lengthens the face in the vertical dimension
Post operative
Fig. 33 Illustration of the submandibular implant, which lengthens a
face vertically by 4 mm as well as provides 4 mm of anterior–posterior
projection
A spatula-shaped elevator with a 1-cm wide blade is
thrust directly under the periosteum and under the orbicu-
laris oris muscle in a vertical orientation at the inferior base
of the maxillary buttress, in the apex of the gingival buccal
sulcus. The overlying soft tissues are swept obliquely upward
over the maxillary eminence by maintaining the elevator
directly on bone. The elevator should always remain on the
bony margin along the inferior border of the malar eminence
and zygomatic arch (Fig. 36).
Manual palpation of the previously marked zonal design
of the malar space anatomy on the skin is performed, while
the underlying elevator mobilizes the tissues directly from
the bone. This maneuver includes palpating the orbital rim
and the upper and lower borders of the zygoma as the eleva-
tor dissects the subperiosteal space within these areas
(Fig. 37).
A lighted fiberoptic Aufricht retractor confirms the ana-
tomic dissection. Once bony margins are reached, further
space expansion is performed only by means of a rounded,
blunter spatula elevator. No dissection should occur into the
soft tissues with a penetrating and forceful motion.
No dissection should occur directly into the area of the
infraorbital nerve. When desired, the periosteum may be
E.O. Terino
mobilized, both lateral and inferior to the infraorbital fora-
men, with a careful scraping motion until the nerve and fora-
men is visualized. This is indicated for placement of
suborbital tear trough implants. Frequent irrigation is per-
formed with antibiotic solution (Bacitracin, 50,000 U/L or
Ancef 1 g/L of normal saline).
Once the space is mobilized, the chosen implant is intro-
duced with a long, curved, serrated clamp placed transversely
across the upper end of the implant and inserted into the pos-
terior zygomatic tunnel while two 10-in. needles swedged on
a 2-0 prolene suture (Ethibond) are placed from inside to
outside in the temporal region and then tied over a large bol-
ster sponge. Should buckling of the implant occur, correct
positioning can be ensured by using a Russian forceps, in
combination with a spatula periosteal elevator, passed both
anterior and posterior to the implant. Fiberoptic Aufricht
retractors or other illuminating instruments are used to illu-
minate the interior of the space, reveal the internal anatomy
and confirm the correct position of the implant.
In the submalar zone, the soft tissues are swept off the
shiny, white, glistening, fibrous tendon of the masseter mus-
cle in an inferior and outward direction. This opens up the
submalar space for approximately 1–2 cm, depending on the
desired choice of cheek shape and the corresponding implant
necessary to achieve it. When adequate anesthesia tech-
niques are used, the intraoral approach permits excellent
visualization of the skeletal anatomy and musculature. This
exposure allows accurate implant placement into zones 1, 2,
and 5 (SM5). It permits the surgeon to place a spatula eleva-
tor above and below the implant to make certain that its
edges are not buckled or that the zygomatic extension of the
implant is not curled. It is not necessary to visualize the
infraorbital nerve, but it is rather easy to do so when required,
or when an implant is used for the suborbital region.
17 Subciliary Blepharoplasty Approach
In the standard subciliary blepharoplasty approach, an inci-
sion is made 3 mm below the lash line, and limited in its
lateral extension to avoid scars in the lateral canthal region.
This approach may be used either in conjunction with rou-
tine blepharoplasty or as an independent route of entry for a
malar implant. When used for implant placement alone, the
incision is limited to a length of 10–15 mm. It is designed
only in the middle to lateral third of the lower eyelid, in the
subcilial region (Fig. 38). Moreover, the dissection inferiorly
provides a sturdy shelf upon which the implant rests.
Tear trough implants can be placed through an external
subcilial blepharoplasty incision, a transconjunctival inci-
sion, or an intraoral route. The tear trough implant is placed
after cutting out a segment, which allows it to surround the
main trunk of the infraorbital nerve. If desired, it can be
3D Facial Volumization with Anatomic Alloplastic Implants 1019

Fig. 34 Both patients demonstrate improvement in a “witch’s chin deformity” by using a vertical extension implant along the lower anterior
mandibular border
1020 E.O. Terino

Fig. 35 A 20-year-old male with prominent nose and deficient lower third chin–jawline. Left: preoperative. Right: postoperative. Top and bottom:
before rhinoplasty, central chin and angle of jaw implants
3D Facial Volumization with Anatomic Alloplastic Implants 1021

secured by one or two sutures to the medial orbicularis mus- 18 Premandible Augmentation
cles or to the inferior orbital rim. Technique
The greatest advantage of the subcilial blepharoplasty
approach is the opportunity for correct positioning, because Extending a centrally placed implant into the midlateral and
the surgeon is able to directly observe the relationship of the posterolateral zones requires only a dissection along the
implant to the inferior orbital rim. inferior mandibular border into the “safe zone” posterior to
the mental nerve. There is a significant constriction and
Table 1 Ideal qualities for facial implants adherence of the tissues to the bone surrounding the mental
Silicone Gore-Tex/ Porex/ foramen called the mandibular ligament. Once these are
Ideal Qualities Rubber Soft Form Medpor Hydroxyapatite released, dissection of the tissues from the posterolateral
Biocompatible 4 3 4 4 zone occurs easily.
Modifiable 4 2 3 3 Although operations to augment the central mandible for
Exchangeable 4 2 1 1 aesthetic purposes have existed for over 50 years (Millard
Resistant to 3 1 3 2 1953) [16], and plastic surgeons have well understood the
Infection advantages of improved nasomentum profile relationships, it
Anatomic contours 4 1 2 2
is only within the last 30 years that methods have been devel-
Visible, palpable 3.5 1 2 2
oped for augmenting the premandible by extending central
Note: 1–4 least–most optimum chin implants over a larger surface area as well and by using
anatomically designed alloplastic devices. These techniques
Table 2 Ideal anesthesia for alloplastic facial contouring also make it possible to alter the shape and size of the mid-
General anesthesia
lateral and posterior aspects of the mandible, and even to
Maintain blood pressure at 90–100 systolic lengthen the submandibular segment vertically.
Clonidine, 2 mg orally preoperatively Access to the premandible space can be achieved by
Local anesthesia either the standard intraoral route or the submental route
Lidocaine solution 0.2 % (Fig. 39). These authors use the submental approach exclu-
Adrenalin 1:800,000 sively for operations that require additional surgery in the
Generous tissue infiltration into malar or premandible space submental and submandibular region, such as liposculptur-
(20–30 ml each) ing and platysmal contouring

"L" extension
Incision

Sulcus

Fig. 36 An intraoral approach

for placement of a malar implant
can be used to dissect the proper Extent of dissection
space and identify and visualize
the internal anatomy for proper
placement
1022
Fig. 37 Malar shell augmentation by the intraoral route showing elevation of the soft tissues over the malar region by staying on the bone with an
elevator and controlling the space between the index finger and thumb
Fig. 38 A subcilliary lower eyelid incision is performed using a skin
muscle flap down to inferior orbital bony margin and penetrating the
periosteum and SOOF layer 4 mm below the orbital rim
In both approaches, the incisions are transverse and 2 cm
long. The intraoral transverse incision is through mucosa
only. The mentalis muscles are then divided vertically
through their midline raphe to avoid transection of the mus-
cle bellies and total detachment from their bony origins
(Fig. 40). This aperture provides direct access downward
E.O. Terino
onto the bony plane and eliminates the muscle weakening
that occurs with customary transection methods.
By adhering to the principle of subperiosteal elevation
on bone, the muscle attachments are elevated from their
origins along the inferior margin of the mandible. This area
does not endanger the mental nerve. The mandibular branch
of facial nerve VII does, however, cross just anterior to the
mid portion of the mandible in the midlateral zone.
Consequently, it is important not to traumatize the tissues
that overlie and constitute the roof of the premandible space
in that region. The mental nerve and foramen can vary in
number and location. Reported anatomic variations consist
of multiple foramina existing between 1.5 and 4.5 cm from
the mid line in a small percentage of individuals. The bony
configuration of the foramen, however, directs the mental
nerve in a superior path upward into the lower lip.
Dissections that remain inferior to the foramen and along
the lower border of the mandible avoid significant danger
of nerve damage.
In one operation, the senior author inadvertently placed a
premandible implant superior to the mental nerves bilater-
ally. The immediate result was compression symptoms in the
form of anesthesia of the lower lip. Unfortunately, other
facial procedures performed at the same time (rhytidectomy
and blepharoplasty) obscured the diagnosis until the swell-
ing had diminished. The implant was repositioned beneath
the nerves on the ninth postoperative day. Replacement of an
implant or repositioning can easily be done within the first
10–14 days. By applying the basic principles of wound heal-
ing taught during residency, the surgeon is able to reenter the
premandible or malar space to replace or reposition implants
prior to the rapid increase in wound tensile strength, which
occurs from 14 to 21 days after the operation.
3D Facial Volumization with Anatomic Alloplastic Implants
a b
Fig. 39 Photos showing both the submental (a) and the intraoral routes (b) for insertion of extended anatomic chin implants
a variations in the location of the mental foramen, which is
b muscle onto the mandibular bone, allows access to, and easy
Fig. 40 Illustration of the central subperiosteal dissection between
the mental nerves down to the inferior border of the central mandible
(a) and location of an extended anatomic implant beneath the mental
nerve (b)
Dysesthesias and paresthesias in small or sometimes
larger areas of distribution of the mental nerve are not com-
mon following alloplastic chin and premandible augmenta-
tion. The symptoms are usually temporary and subside
within 4–6 weeks.
Clinically, there appears to be a definite correlation
between the occurrence of nerve symptoms and the degree of
difficulty that the surgeon experiences in placing the implant.
There is no correlation, however, with the size and shape of
the implant. Extended alloplastic anatomic-contoured
implants contain specific notches designed to avoid pressure
around the mental foramen. They provide for normal
1023
8–10 mm up from the lower mandibular margin.
Additional incisions may be made posterior to the mental
nerve to accurately place lateral mandibular bars and
implants that extend into the midlateral and posterolateral
zones. A 3-cm horizontal mucosal incision made in front of
the first molar, followed by direct penetration through the
dissection of, the premandible space beneath. This aperture
assists accurate placement of mandibular angle implant and
also facilitates positioning the posterior extensions of other
implants to augment simultaneously the central mentum and
the midlateral zones anteriorly.
The author has already stated that integrity of the mental
nerve and easy positioning of the implant beneath it can be
assured through fiberoptic techniques. A narrow, malleable
ribbon retractor is utilized to distract the soft tissues for the
placement of premandible implants into their tunnels. To
position a long, extended premandible implant, a tunnel or
space must be created that is longer posteriorly than the
length of the implant. The implant can then be inserted from
the central incision far into one side and then be folded upon
itself to be introduced into the opposite mandibular tunnel.
Careful palpation, lateral positioning, and observing the cen-
tral marking of the implant directly over the central mental
protuberance are keys to accurate placement.
Posterolateral implants are placed through a posterolateral
incision. The posterolateral incision is transverse and is located
approximately 1.5–2 cm anterior and adjacent to the angle of
the mandible (see Fig. 29). Appropriate space for placement is
created by making a direct dissection onto bone and subperi-
osteally beneath the masseter muscle. A curved elevator is
used to dissect around the posterior aspects of the ascending
ramus in the angle region. In this way, implants designed to fit
1024
Fig. 41 Illustrations and photographs of a mandibular angle implant insertion using a curved clamp and placing it in an upward and posterior
position over the mandibular angle and ascending ramus
securely around the angle of the mandible can be accurately
positioned (Fig. 41). Secure closure of muscle and mucosa
must be done with all intraoral facial implant incisions.
19 Preoperative Planning
19.1 Evaluation
Patient evaluation for total alloplastic facial augmentation
includes gathering the following essential data:
• What problem does the patient want you to solve?
• Get the patient’s verbal description of his/her “ideal
scene” appearance of facial change.
• Precisely understand the exact location and contour
change they desire to achieve.
• Patient “homework assignment”: bring magazine photos of
specific “do’s & don’ts” on desired anatomic part changes.
• Have older patients bring a variety of earlier personal
photos.
• Use computer face photos (5 views) and imaging technol-
ogy to do the consultations.
• Use an anatomic facial zone model and facial type
analysis.
Preoperative planning for all plastic and reconstructive
surgery is the critically essential step for achieving success-
ful results. For aesthetic surgery, such planning must include
accurate and definitive communication with the patient,
whose perceptions and expectations the surgeon must under-
stand completely. For traditional surgery on aging patients,
communication about their needs and wishes may be rela-
tively simple. They wish to have their prior youthful con-
tours and facial features restored as completely as possible.
E.O. Terino
With the passing years, individuals accommodate to the
slow, gradual changes that take place in the soft tissue con-
tours of their faces. The limited technical results of routine
tissue repositioning and tightening techniques from tradi-
tional facial aesthetic surgery may therefore be acceptable to
them, because they do produce some significant visible albeit
limited postoperative improvements.
Well-established techniques for altering facial contours and
facial promontories go beyond routine surgery in that they may,
if desired, change a patient’s inherited anatomic configuration.
Following facial implant contouring, patients experience much
improved visual and perceptual images of themselves.
Although there presently is an assortment of ever-evolving
tools for measuring aesthetic skeletal parameters, precise
implementation of facial form still remains challenging,
even in the most experienced hands. Therefore, before the
surgeon attempts an alloplastic facial contour alteration, it is
imperative that he or she knows exactly what facial image
the patient desires. The authors request their patients to mod-
ify photographs of themselves and bring them in, or to pro-
vide, from fashion magazines or other sources, examples of
facial contours that they admire, namely, faces that they feel
look similar to their own but are more attractive in the perti-
nent skeletal areas (Fig. 42). Although this process may run
contrary to standard residency teaching, it creates an under-
standing of patients’ expectations by providing invaluable
visual insights and imagery to discuss. Most patients do have
very precise ideas about the images of facial contours they
wish to emulate. Therefore, when they do not, it is easy to
discover that their expectations cannot be met. In elective
operations, surgeons must not undertake what they are not
sure they can accomplish, especially when the patient’s own
visually described goals are poorly defined. Overall, the
authors find computer imaging technology to be indispens-
able in this process.
3D Facial Volumization with Anatomic Alloplastic Implants 1025

Fig. 42 Patients are requested to bring photographs of faces they resemble and facial contours they resemble

Fig. 43 Preoperative markings are made on all patients’ faces the morning of surgery to outline their zonal anatomy and bone structure

During patient consultations, it is important to determine
the desired anatomic zones to augmentation, because, by
definition, this is responsible for the patients postoperative
appearance. Multiple consultations with the patient are
important to precisely define the final desired outcome. On
the morning of surgery, quality time spent in marking, mea-
suring, and discussing surgical details with the patient is
essential. Finally, by drawing the preoperative configurations
of the pertinent regional and zonal anatomic landmarks on
the patient’s face, the surgeon is provided with guidelines for
accurately performing the intraoperative surgical dissection
and implant placement (Fig. 43).
1026
20 Postoperative Care
Postoperative care for facial implants is straightforward
and uncomplicated. Perioperative oral antibiotics are uti-
lized. At the present time, cephalosporins are favored. Prior
to the start of surgery, 1 g of Ancef is given intravenously
by the anesthesiologist. Ten milligrams of Decadron are
also given intravenously during the surgery to control post-
operative edema. During the postoperative period, a 5-day
diminishing course of steroid in the form of a Medrol dose
pack is taken orally. For the first 12 h, cold compresses are
applied intermittently to the operative site either in the mid-
face or premandible region. No bandages are used. Removal
of intraoral mucosal and external subcuticular sutures is
unnecessary. A soft diet is maintained for 10 days. It is
highly recommended that the patient reclines at a 45° angle
and in the supine position for at least 1 week. Vigorous
physical activity is not permitted for 4 weeks. After which,
patients may engage in any and all types of exercise
activities.
Fig. 44 Two examples of unattractive abnormal disfiguring contour abnormalities when the wrong size and shape is used and placed in the wrong
position
E.O. Terino
21 Complications
The major disadvantages of the use of alloplastic materials
are several:
• Possibilities of severe infection, especially with porous
materials, which become infiltrated with fibrotic ingrowths
or bone sequestrum, which complicates ready removal
• Contour abnormalities of an unattractive or even disfigur-
ing nature when implants do not have the proper shape,
size, and positioning (Fig. 44)
• Possibilities for facial nerve and musculature damage due
to excessive and inappropriate trauma during dissections
to introduce or to remove the implant materials (Fig. 45)
Complications from the intraoral approach include dyses-
thesias from damage to the infraorbital nerve or motor dys-
function of the orbicularis oris musculature (Fig. 46). Nerve
symptoms may be attributed to transection of small branches
in the lip during the incision or direct damage to the major
3D Facial Volumization with Anatomic Alloplastic Implants 1027

Fig. 45 Nerve complications following facial implants occur in less than 1 % of patients. Most nerve injuries are temporary. One typical injury involves facial
nerve branches to the frontalis and orbicularis oculi muscle. Both patients experienced complete recovery at 6–8 weeks following surgery
1028
Fig. 46 Chin augmentation can be accompanied by damage to the marginal mandibular branch of the facial nerve. Complete resolution almost
always occurs by 6–10 weeks following surgery
nerve bundle during dissection or pressure impingement on
the nerve from an implant.
These complications, however, are rare and almost nonex-
istent when the previously stated guidelines to dissection are
applied.
Use of traditional transverse incisions through the muscle
pillars of the zygomaticus produce traumatic transection,
resulting in transient and perhaps even permanent damage to
muscle function. This can inhibit normal lip elevation.
During the subciliary dissection, the infraorbital nerve is
also intentionally avoided. An incision is made in the perios-
teum 3–4 mm anterior to the orbital rim along its lateral
aspect, to obviate potential adhesions that may result in
ectropion and lower lid contracture. A skin flap should never
be used, because it always shrinks and predisposes to eyelid
retraction and ectropion. By utilizing a skin–muscle flap
approach, however, there should be no trauma to the orbicu-
laris muscle.
Excessive muscle damage, with bleeding into lid tissues,
stimulates fibrosis and contracture within the middle lamella
of the lower eyelid, producing ectropion. Standard lateral
E.O. Terino
canthopexy techniques are used to minimize this possibility
(Fig. 47). Resection of skin and muscle flap should be con-
servative, i.e., minimal to no excision, because of additional
traction exerted on the lower eyelid from the volume expan-
sion caused by the implant under the malar tissues.
Incisions that transact muscle fibers not only lead to inad-
equate closure but also may create weakness and laxity of the
mentalis muscle, thereby contributing to a potential for chin
ptosis. Ptosis of the mentalis musculature and soft tissue
mound of the central mentum is described in the literature as
one of the controversial aspects of alloplastic implants. Indeed,
the possibility for deformities, such as central drooping. and a
“witch’s chin” does exist. They can be prevented, however, by
using the previously described vertical entrance wound and
securely approximating the mentalis muscle pillars during clo-
sure. The mentalis muscle can easily stretch to accommodate
the introduction easily of large, extended anatomic implants.
Central implants except for large customized “square
front” implants almost always create a central mound defor-
mity with an adjacent “anterior mandibular prejowl sulcus”
and potential “witch’s chin” or “drooping” appearance.
3D Facial Volumization with Anatomic Alloplastic Implants
Fig. 47 Excessive bleeding and muscle damage in the lower eyelid can result in an ectropion. Left: pre-correction, and right: 6 months after lateral
canthopexy
Conclusions
Plastic surgeons are now better prepared to fulfill the pri-
mary goal of facial cosmetic surgery. By manipulating
and combining the various new alloplastic techniques,
they can restore, rejuvenate, and enhance hereditary facial
forms and improve aging changes.
Whereas soft tissue plane tightening and lifting tech-
niques are essentially two-dimensional, skeletal augmen-
tation represents surgery of the deepest plane and is
three-dimensional in nature. The use of implants on the
facial skeleton represents volume and mass augmentation
and alteration of facial form. Manipulations of the other
three planes (i.e., skin, subcutaneous fat, and SMAS) are
attempts to reverse aging qualities of loosening, sagging,
and drooping in a two-dimensional fashion, which are
limited by the bioelastic dynamics of aging tissues.
Skeletal augmentation now represents a final phase for
facial plastic surgery. Three-dimensional volume–mass
modifications of the fourth plane skeletal framework
enable surgeons to dramatically or subtly alter inherited
1029
facial images, as well as compensate for the deterioration,
sagging, and diminution of facial tissue mass that comes
with age.
Now, virtually all aspects of the facial skeleton can be
augmented satisfactorily. It can truthfully be said that
alloplastic implants may become the “open sesame” of
aesthetic surgery, the door by which facial changes can be
made that are almost “magical” and heavily rely on the
imagination and the skill of the surgeon.
References
1. Rogers BO (1976) The development of aesthetic plastic surgery: a
history. Aesthetic Plast Surg 1:3
2. Skoog T (1969) Useful techniques in face lifting presented at the
meeting of the American Association of Plastic Surgeons, San
Francisco, April 1969
3. Mitz V, Peyronie M (1976) The superficial musculo aponeurotic
system (SMAS) in the parotid and cheek area. Plast Reconstr Surg
58:80–88
1030
4. Lennon ML (1983) Superficial fascia rhytidectomy: a restoration of
the SMAS with control of the cervico mental angle. Clin Plast Surg
10:449–478
5. Guerrero-Santos J (1978) The role of the platysma muscle in rhyti-
doplasty. Clin Plast Surg 5:29–49
6. Terino EO (1992) Alloplastic facial contouring: surgery of the
fourth plane. Aesthetic Plast Surg 16:195–212
7. Tessier P (1971) The definitive plastic surgical treatment of the
severe facial deformities of craniofacial dysostosis: Crouzon’s and
Apert’s diseases. Plast Reconstr Surg 48:419–442
8. Rubin LR, Walden RH (1955) A seven year evaluation of polyeth-
ylene in facial reconstructive surgery. Plast Reconstr Surg
16(5):392–407
9. Gonzales-Ulloa M (1957) Selective regional plastic restoration by
means of esthetic unities. Rev Bras Cir 33(6):527–533
10. Hinderer UT (1975) Malar implants for improvement of the facial
appearance. Plast Reconstr Surg 56(2):157–165
E.O. Terino
11. Terino EO (2008) Alloplastic contouring for suborbital, maxillary,
zygomatic deficiencies; Putterman’s cosmetic oculoplastic surgery.
Saunders, Elsevier, 4th edn. p 227, 250
12. Terino EO, Edward M (2008) The magic of mid-face three-
dimensional contour alterations combining alloplastic and soft tis-
sue suspension technologies. Clin Plast Surg 35:419–450
13. Terino EO (2000) Alloplastic contouring in the premandible-
jawline lower third facial aesthetic unit. Art Facial Contouring
153:165
14. Carboni A, Gasparini G, Perugini M, Renzi G, Matteini C, Becelli
R (2002) Evaluation of homologous bone graft versus biomaterials
in the aesthetic restoration of the middle third of the face. Minerva
Chir 57(3):283–287
15. Sevin K, Askar I, Saray A, Yormuk E (2000) Exposure of high-
density porous polyethylene (Medpor) used for contour restoration
and treatment. Br J Oral Maxillofac Surg 38(1):44–49
16. Millard RD (1953) Chin implants. plast and reconstr surg 10:70.
 Facial Lipofilling
Domenico De Fazio and Laura Barberi
1 Introduction
The face is considered the peculiar feature of each individual,
permitting his or her recognition, and is the first element in
distinguishing people. It starts at the anterior part of the head
beginning from the forehead to the chin, including hairs,
forehead, eyebrow, eyes, eyelids, nose, mouth, lips, teeth,
skin, chin and the rest of the mandibular outline.
The face is one of the most important and complex means
of expression, which everyone can use to communicate and
transmit sensations and emotions, and is what characterises
ourselves. Nevertheless, time, excessive weight loss, medical
therapies or other things can cause some zones of our face to
lose some volume, changing their original shape and impact-
ing dramatically on our face’s harmony.
Individual morphology is dictated by a set of unique fea-
tures depending on the underlying bone skeleton, in combi-
nation with muscular, cartilaginous, adipose and cutaneous
structures. With the current state-of-the-art plastic surgery, if
an individual is not satisfied with his or her own appearance,
he or she can undergo treatments and surgeries to modify
that appearance. The face is composed of multiple structures
that, in the ageing face, display changes in mass and skeletal
proportion and an atrophy with redistribution of subcutane-
ous fat tissue [18], a general loss of suspension by supporting
structures, an excess and a folding of the skin. The work by
Schaverien et al [20]. describes the fat tissue compartments
in the face, explaining that fat tissue is localised in well-
defined compartments, separated by fibrous bands that pre-
vent their movement to another compartment. This new
description of the ligaments of the face and the fatty anatomy
of the face allows a better understanding of the ageing pro-
D. De Fazio, MD (*)
Divisione di Chiurgia Plastica, Clinica San Pio X, Milan, Italy
e-mail: info@domenicodefazio.it
L. Barberi, MD
Chirurgia Plastica e Ricostruttiva, Università di Siena, Siena, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_70
cess, in which we see opposing phenomena of lipoatrophy
and lipohypertrophy in adjacent zones. Osseous and carti-
laginous systems serve as supports; the musculoaponeurotic
superficial system, by means of the interlobular fibrous septa
in the adipose tissue, connects directly to the skin to ensure
its stability. The support system relaxes with ageing, as we
see with the lower eyelid ectropion, a consequence of the
elongation of the lateral canthal tendon or with the nose pto-
sis due to changes in cartilaginous and fibrous support. The
support for the skin cover, assured by superficial aponeurotic
system, lessens, creating a number of well-known folds and
grooves connected to the ageing process [28].
We must keep in mind that beauty is expressed by facial
harmony, which in turn is the consequence of a perfect balance
between its components: eyes, nose, zygoma, mouth, teeth
and chin. The central portion of the face, particularly, is the
feature that immediately meets the eyes of the persons that
speak with us or look at us and is therefore our visiting card. A
well-proportionate face can transmit pleasance and harmony
to the people who look at it; on the contrary, the zygoma not
defined or emptied, a look particularly marked by eye bags,
transmits an impression of tiredness and carelessness.
Autologous fat graft restitutes volume to altered features,
using the fat tissue of the patient and thus eliminating the
possibility of allergic reactions, which can on the contrary
occur when using other fillers.
Facial lipofilling or lipostructure consist of infiltrating, in
well-defined zones of the face, some fat tissue usually har-
vested in places like the abdomen, thighs, buttocks or knees;
in doing so, we restitute a juvenile appearance to features
rendered heavy and fatigued by stress and relaxed or altered
by defects that are present since birth [2].
2 Facial Embryology
The face represents for every person the most prominent fea-
ture. It is constituted, starting from below, by the chin, the lips
surrounding the mouth, the philtrum of the upper lip, the
1031
1032 D. De Fazio and L. Barberi

external nose, the cheeks, the zygoma, the eyes with eyelids
and eyebrows and the front. On the sides we find the auricles.
The face begins its development in the fourth week. In
this phase, neural crest cells give rise to skeletal and connec-
tive tissues, forming the main part of the skull’s and face’s
skeleton.
It develops at the level of the contour of stomodeum
(primitive mouth’s roof) [25]. In fact, this region is furrowed
by this depression, called the stomodeum, which is limited
above by the frontonasal process, below by the fist pharyn-
geal arch and laterally by the two maxillary processes [22].
From these processes, the embryo’s face develops,
through complex morphogenetic movements that will mod-
ify its form, size and relationships with various parts, deter-
mining fusions in specific regions.
At the end of the fourth week, the two mandibular pro-
cesses fuse on the median line, constituting the chin and the
outline of the lower lip.
At the end of the sixth week, the two nasal median pro-
cesses give, after fusing, the median massif of the face,
formed by nasal septum, vomer, incisive bones and upper lip.
Lateral nasal processes, on the contrary, will form the nasal
wings and the nasolacrimal duct [24].
The two maxillary processes will give rise to three differ-
ent fusions: they fuse with intermaxillary process, forming
the maxillary arch and the upper lip. At their periphery they
fuse with the underlying mandibular processes reducing the
mouth opening. The upper margins will instead fuse with the
nasal lateral processes, forming the lateral masses which will
give origin to the cheeks.
During those fusion processes, the eye germs will move to
their definitive place, from their original situation outside
and on the sides of the head.
3 Anatomy
The skull is divided in two portions: neurocranium and
splanchnocranium.
The cranium (neurocranium) is formed by frontal, eth-
moidal, sphenoidal, occipital, temporal and parietal bones.
The face massif (splanchnocranium) is formed by maxil-
lary, nasal, lacrimal, palatine, inferior turbinate, zygomatic,
vomer and mandibular bones.
The skull gives insertion to various muscle groups
(Fig. 1), which can be divided in extrinsic and intrinsic
muscles:
• Extrinsic muscles originate outside the skull (neck, trunk)
and insert on it.
• Intrinsic muscles are entirely located in the skull, where
they have both their origins and their insertion. They are
constituted by skeletal or masticatory muscles and mimic
the expression of muscles.

Frontalis

Eyebrow corrugator
Orbicularis oculi

Temporalis

Nasalis

Canine
Zygomaticus
Buccinator
Masseter
Platysma

Orbicularis oris
Triangular

Fig. 1 The muscles of the face Mentalis

Facial Lipofilling
a b
Fig. 2 (a) Face vascularisation. (b) Face innervation
Apart from those in the skull, we find other muscles:
those of the ear pavilion, the eyeball, the middle ear and the
tongue.
The skin covers all the muscles, fat tissue, vessels and
nerves. The vessels are quite numerous, since the face is
much vascularised, and the nerves are partly motor and
partly sensitive (Fig. 2).
In the face there are zones, of little dimensions, which
present a specificity, due to the anatomical and physical fea-
tures of the composing structures: the skin, the subcutaneous
tissue, the underlying muscles and the deep bony planes’ set-
ting; moreover, there is the presence of folds and expression
grooves.
These zones, so peculiar, are termed “facial aesthetic
units” and include the frontal, palpebral and malar zone; the
naso-labial grooves’ zone; the nasal, labial, mental, submen-
tal, supraorbital and orbital zone; and the cheek zone, in turn
divided into the infraorbital, zygomatic, buccal and parotid
zones. When we operate on the face, it’s a must to know the
differences between these zones and to respect their relation-
ships, in order to avoid completely transforming one’s face
harmony [12].
4 Techniques in Use
Lipofilling permits to transfer autologous fat from one site of
the body to the other.
The idea of enlarging some bodily parts using adipose tis-
sue is not a new one: in 1919 appeared the first paper on the
behaviour of autologous fat tissue injected to correct the
1033
Te
m
po
ra
lis
Zygomatic
us
Buccinator
r
ibula
Mand
al
vic
Cer
body contour. Since then, the technique of lipofilling has
gained widespread diffusion, still keeping some shortcom-
ings and contraindications.
The injection of fat tissue taken from the patient is noth-
ing less than an autologous tissue graft.
A graft is defined as the transfer of one or more tissues
without maintaining the vascular continuity with the original
site: this is what happens in lipofilling, where the fat tissue
aspirated in excess zones is reinjected in distant sites, in the
body area to treat. Since there is no vascular connection, the
tissue transferred can survive only if it comes in contact with
well-vascularised tissues that initially will feed it by imbibi-
tion and later forming new vascular connections. Large
amounts of fat injected do not allow all the adipocytes to
come in contact with the receiving tissue, and they will nec-
essarily develop necrosis. Facial lipofilling is a technique
that allows us to obtain more definition in given facial zones,
which for various reasons may have lost their original
volume.
Nevertheless, this surgical procedure has for a long time
produced deceiving results, because the injected fat under-
went an unavoidable resorption. With time, results became
better, but only in 1997, with Sidney Coleman, that the piv-
otal turn occurred [4].
Coleman’s technique consists in harvesting the fat from a
body part where it is in excess, after local infiltration, through
a specific needle, with an anaesthetic solution compounded
with a vasoconstricting drug. For the face, the fat tissue is
harvested after infiltration with Klein solution, through a
3-mm tube, which has a point particularly designed to avoid
damaging the adipocytes. The tube is connected to a 10-ml
1034
Fig. 3 Coleman’s centrifuge
Fig. 4 Pattern of the adipose graft in the malar zone
syringe, which the operator uses in a way that does not dam-
age the fat tissue, regulating the suction pressure.
The fat tissue harvested is subsequently centrifuged for
about 3 min at 3,000 rpm (Fig. 3), to obtain only pure fat,
excluding the nonviable cellular component and excess flu-
ids like anaesthetics, saline and blood.
The tissue is then implanted in facial zones to treat, by
means of 1-ml syringes connected to a very thin (1.5 mm)
cannula, which allows the accurate placing of small volumes
of fat tissue, using small subcutaneous tunnels. To facilitate
maximal healing of the graft, the fat tissue is injected at vari-
ous depths and criss-crossing the injection tunnels is done
(Fig. 4) [3].
Coleman could thus obviate two great constraints of tradi-
tional lipofilling:
• The first related to the damage that fat cells sustained dur-
ing the suction: an adipocyte so altered has lost the heal-
ing capability. Using adequately pointed cannulae, cells
D. De Fazio and L. Barberi
are not damaged but remain intact and can thus survive in
their new location [26].
• The second question referred to the need to implant the fat
cells in contact with well-vascularised tissues, so as to
ensure their survival, hence the idea of infiltrating fat in
multiple small tunnels, with a small amount of fat tissue in
each. This dense tunnel net creates a veritable “structure”
in multiple layers, hence the term “lipostructure” [5–13].
The main indication of this technique is facial rejuvena-
tion and defect correction, which are fulfilled modifying
facial contour and increasing the volume of some parts [6].
This technique has many advantages: it is a less invasive
procedure, thanks to the Coleman cannulae; a more natural
result is obtained and the absence of rejection because it can
be performed with local anaesthesia on an outpatient basis.
Another peculiarity of this procedure is that it can be repeated
any time it is desired to increase the volume, when the results
of the first session are suboptimal [7].
Another technique is the one developed by Carraway,
which differs from the previous way the harvested tissue is
processed. It is more practical and quick, since the tissue is
simply washed with Lactated Ringer’s or saline in a specific
net strainer, before being transferred in the syringes for
grafting (Fig. 5). This system allows preparation of bigger
quantities in lesser time compared to the Coleman’s tech-
nique [2].
A disadvantage of these techniques, on the other hand, is
that the grafted fat tissue unavoidably undergoes a certain
resorption. The author’s experience, gained in many years in
many anatomical regions of the body [8], allows us to affirm
that in normal conditions the percentage of healing is indeed
very high, around 80 % of the injected volume. A completely
different situation is that of the lips, where the initial resorp-
tion is much more than in other facial districts.
The common goal of all the different harvesting tech-
niques is to obtain small particles of fat tissue, or groups of
fatty cells, without impairing their viability, and thus, the
studies are aimed to define the best technique, in order to
assure the best possible [21]. Even if a small number of
studies notes differences in viability and quality of the
graft, related to the different harvesting sites, others, more
numerous, affirm that the sites commonly used, like abdo-
men, flanks, thighs and knees, provide the same proportion
of viable cells [19].
A study showed that liposuction performed with a lipo-
suctor or using 60-cc Luer-Lock syringes causes a very small
cellular damage and shows 98–100 % of viable cells with
both techniques; another animal study also supports these
results, finding equal numbers of viable adipocytes regard-
less of the used technique [17].
The harvesting is done after infiltrating the areas to treat
with a lidocaine 0.5 % solution with adrenaline 1:200,000,
Facial Lipofilling 1035

Fig. 5 Carraway’s technique: rinsing in the strainer

obtained by mixing 20 ml of lidocaine 5 % and 0.5 ml of

adrenaline 1:1,000 in 80 ml saline.
The amount of infiltrated solution depends on the fat tis-
sue volume we want to remove and usually is in a 1:1 ratio
with the aspirated volume. The infiltration is performed with
a 14-gauge needle, and before beginning the liposuction, we
wait 10 min for its effect. The cannula we prefer is the blunt-
pointed Mercedes type, because it minimises tissue disrup-
tion and trauma to fibrous septa, neurovascular bundles and
derma. The multiple holes help to harvest a bigger volume of
fat tissue in each passage. The most important variable in
this harvesting is the maximal negative pressure that we
apply. Usually, 300–350 mmHg are the maximum negative
pressure we can use for liposuction in the preparation of a
lipofilling. If 60-cc Luer-Lock syringes are used, these are
Fig. 6 Celution system
put under suction by means of a stop in the piston, creating
the negative pressure and making the aspiration easier. The
ideal treatment for fat tissue should separate healthy adipo- cells in the patient’s fat tissue through a fat enzyme digestion
cytes and regenerative cells (ADRCs) from cellular compo- procedure with subsequent enrichment of the same patient’s
nents to discard, with minimal air exposition and minimal fat tissue with the cell fraction previously separated during
manipulation. It is necessary to discard as well the blood the surgery.
content, the oily remnants and other exfoliating elements, This mixture of fat tissue, regenerative stem cells and
since they promote an inflammatory response that impairs growth factors is then used for facial lipofilling. This method
the graft’s healing. allows better angiogenesis, reduced cell apoptosis and mod-
Lipostructure with fat tissue enriched with regenerative ulation of the local inflammatory response.
and stem cells derived from autologous fat tissue (ADRCs) is A crucial need for this technique is thus the presence of
used by the author since 2009. This technique involves the localised fat masses, from which it is possible to harvest the
use of lipofilling enriched with regenerative cells and stem needed amount of tissue.
cells derived from fat tissue in one surgical time [27]. The technique introduces the first 100 cc of lipoaspirates
To optimize the best healing of the grafted fat tissue, in the “Celution” device, to be processed and draw preop-
the fat taken from the patient is “enriched” with regenera- eratively regenerative stem cells and growth factors derived
tive cells harvested from the same patient’s adipose tissue from adipose tissue (ADCRs), through digestion of the fat
(ADRCs) [16]. tissue by means of the proteolytic enzyme “celase”. At the
Using the Celution System (Cytori Therapeutics, Inc.) end of the procedure, which lasts 60 min, 5 cc of regenera-
(Fig. 6), it is possible to separate regenerative cells and stem tive cells of adipose origin (ADRCs) is obtained. The
1036 D. De Fazio and L. Barberi

remaining harvested tissue is collected in a closed system

sterile bag (Puregraft), in which a lipodialysis is performed
by means of a bilaminar membrane system. The first mem-
brane performs selective filtration, which allows the pas-
sage of exfoliating cells, red blood cells and fluids,
including the infiltration substances, which are collected in
a bag. The second membrane, sort of a “U-flux” filter,
allows the elimination of the elements to discard and keeps
the purified fat tissue. The system reduces the liquid con-
tent of the tissue to implant, which is proportional to the
drainage time to which it undergoes, to obtain a graft that is
more or less dense, depending on the surgical needs. It does
not need centrifugation, and it is possible to process 100 cc
in about 10 min.
The adipose tissue prepared with the Puregraft bag is then Fig. 7 Zygoma lipofilling
enriched with ADRCs, before the implant.

5 Author’s Preferred Technique

In facial lipofilling, the author’s preferred technique is the

one described by Sidney Coleman, although it’s possible to
use Carraway’s technique and the technique with Puregraft
with excellent results. Concerning the lipofilling enriched
with regenerative and stem cells, this is a technique that
nowadays finds an ideal use in breast and buttocks
lipofilling.
The following facial regions are usually treated and
remodelled with lipofilling:

• Frontal area: the glabella is a generally convex zone,

which loses this appearance with ageing and becomes
concave. The skin of the glabella, moreover, often shows
wrinkles sustained by corrugator and procerus muscles.
Lipofilling with 1–2 cc of fat tissue allows usually to cor-
rect this depression and the vertical grooves, if visible; it
is performed with a Coleman style I cannula, inoculating
from various directions. In correcting the glabella, it is
best to associate also repeated injections of botulinic
toxin, which allow the reduction of the wrinkles. The
temporal region undergoes lipoatrophy and forms a
depressed area that underlines the temporal ridge and
sometimes the border of the zygomatic arch. Sometimes
it underlines also the supraorbital border, which becomes
protruding and is a feature of ageing. This region inferi-
orly is in contact with the lower eyelid, creating a single
anatomic unit which is corrected in the same time. The
implanted fat tissue volume ranges between 2 and 6 cc,
by means of a Coleman style I cannula, starting the injec-
tion from the deepest bony plan to the most superficial
subcutaneous plan.
Fig. 8 Harvesting cannula
• Zygomatic-malar area: with this technique it’s possible to
enlarge the zygoma without resorting to prostheses, and
the result will be more natural, with a less sharp and more
rounded zygomatic contour. In less evident cases, the
lipofilling is performed through a medial approach
(Fig. 7), lateral to the nasal wing and latero-inferior to the
external canthus, as always in the face creating the
approach with an 18-G needle and then with a curved or
straight Coleman style II cannula, implanting 4–8 cc of
adipose tissue in many interlaced layers.
• The fat tissue pattern depends as well on the surgeon’s
aesthetic sense, since he must ideally remodel the
zygomatic area. In cases of more advanced ageing, lipo-
filling is associated to face lifting [13]. Personally, the
author prefers performing the lipofilling at the end of the
Facial Lipofilling
A. Collection with 1.5 mm cannula
B. Collection with 2.5 mm cannula
Fig. 9 Harvested fat
lifting procedure, placing 4–10 cc in each zygoma, inject-
ing the fat tissue deep in a plan not subjected to detach-
ment, which has maintained a good vascularity.
• Palpebral/periorbitary zone: the harvesting of the adi-
pose tissue for eyelid lipofilling involves using the
infiltration 1.5-mm needle multiperforated (Fig. 8), to
aspire the fat obtaining a tissue without irregularities
and very thin (Fig. 9). The upper eyelid may have a
skin and fat excess in its medial portion, but often in
the ageing process, lipoatrophy occurs which causes a
hollowed eye, due to the presence of shadows.
Lipostructure is performed either after a blepharo-
plasty to remove the skin excess or in cases of atrophy
without skin excess to recreate convexity and fullness
in the upper eyelid. The area treated with preseptal
implant and always under orbicular muscle extends
from the superior palpebral groove to the superior
orbital border, with a lateral, medial and superior
access. With Coleman style III micro-cannula 19 G or
18 G, 1.5–5 cc is injected.
• The lower eyelids are mostly characterised by the pres-
ence of the tear trough, a deformity that marks the so-
called eye bags (excessive depression of orbital furrow)
and the presence of apparent fat bags (Fig. 10) [11],
with a marked or light scleral show due to a tendency of
having senile ectropion. Lower eyelid lipofilling must,
starting from the malar zone, sustain and push up the
inferior palpebral vector (Fig. 11a). With Coleman style
II micro-cannula 18-G or 19-G, entering medially from
the cheek and inferior to internal canthus, the entire
inferior palpebral area is corrected with 2–5 cc of adi-
pose tissue. The placing is deep over the bony structure
and under the orbicular muscle, performing various to
and fro movements with the syringe, to avoid creating
elevated masses and protrusions (eyelid skin is very
thin and separated from the underlying fibrous tarsal
articles by the orbicularis palpebrarum muscle). It is
1037
Fig. 10 Lower eyelids lipofilling, before and after
possible to correct the jugal-palpebral furrow, often too
deep, and to correct upper eyelids which have an exces-
sively wide pretarsal space.
• Naso-labial and marionette furrow: in this area, with time
there is a reduction of soft tissue, forming furrows that
will be filled by lipostructure. To achieve a good correc-
tion and reduce the depth of naso-labial and “marionette”
furrows, it is necessary to act at the same time on the skin
retraction caused by muscle-cutaneous adhesions. A sub-
dermal dissection of fibrous attachments between skin
and underlying structures should be performed avoiding
any skin incision. The dissection is carried with an 18-G
needle, which allows to detach the cutaneous tissue, free-
ing it from adhesions and thus creating a perfect pouch for
the adipose graft (Fig. 12).
• Combining subcutaneous dissection and lipofilling, it
will be possible to fill the furrow’s depression, prevent-
ing recurring adhesions. The upper part of the naso-labial
and “marionette” furrow is treated injecting along the
furrow’s axis, as well as perpendicularly to it (Fig. 13).
The entrance is usually double, lateral to the nasal wing
and at the labial commissure externally. The injected adi-
pose tissue varies between 2 and 6 cc for each furrow,
and 1–3 cc for the marionette’s, with a Coleman style I
cannula.
• The lips: a careful preoperative lip analysis requires
evaluating the patient while he or she laughs and is at
rest. The distance between the columella and the ver-
million of the upper lip margin should be determined.
When this distance is too big, ideally an upper lip lift-
ing is needed. Ideally the distance between the colu-
mella and Cupid’s arc in the woman is 14 mm.
Moreover, generally the upper lip has 25 % more vol-
ume than the lower lip. The shape of the upper lip is
fuller in Cupid’s arc, and the normal vertical distance
of the upper lip is 10 mm, while that of lower lip is
12 mm (Fig. 14).
• Lipofilling is performed with a Coleman style II cannula,
entering 2 mm above the external commissure, between
1038 D. De Fazio and L. Barberi

Fig. 11 Phases of lower eyelids lipofilling. (a, b) Injection; (c) right lower eyelid not corrected, left eyelid corrected. (d) Both lower eyelids
corrected

Fig. 12 Nasogenian furrow lipofilling Fig. 13 Lipofilling of the “marionette” furrows

Facial Lipofilling
Fig. 15 Lipofilling of the lips
Fig. 14 The ideal lip shape
Fig. 16 Chin lipofilling, before and after
buccal mucosa and orbicular muscle. When needed, it’s
possible to increase as well the philtrum’s volume; the
injected volume ranges from 3 to 5 cc.
• The lower lip gets the same volume of adipose tissue if we
want it more protruding; the graft is performed in every
plan from mucosa to skin (Fig. 15).
• Chin: The chin can be smaller, due to lipoatrophy or bone
resorption of the mandible, and thus is augmented in
facial rejuvenation procedures. With accesses at the ante-
rior third of mandibular margin and medially submental,
1039
with a Coleman style III cannula, 5–10 cc of fat tissue is
injected, starting from the bony plan and becoming more
superficial under the skin (Fig. 16)
• Mandibular margin: The mandibular margin is often cor-
rected to recreate a youthful appearance of the face, render-
ing the mandibular contour more regular. It is frequently
necessary to associate a liposuction in the submandibular
zone to the injection of adipose tissue at the mandibular
margin and the lipostructure at the junction between the
mandibular margin and the anterior cervical region (Fig. 17).
1040
Fig. 17 Mandibular margin lipofilling, before and after
• Nose: the nose contour correction finds an indication in
the congenital or iatrogenic “saddle” nose. With Coleman
style III cannula, it’s possible to correct the dorsum,
approaching it from the glabella, with 1–2 cc in the sub-
cutaneous space. In secondary cases, with adherent and
scarred skin, the greatest care must be taken during the
dissection; to avoid lesions to the skin, it’s most important
to perform infiltration with local anaesthetics, which
eases this dissection. Also very important is the improved
skin quality produced by the lipofilling. Due to very
fibrous scarred zones, this site quite often necessitates
more than a procedure (Fig. 18).
• Facial atrophy: This is caused by disorders (Romberg’s
disease) or is occurring in HIV-positive patients who use
certain agents (protease inhibitors). These disorders can
involve some isolated zones, or a whole hemiface, with
lipoatrophy in varying degrees. The techniques discussed
D. De Fazio and L. Barberi
for the different anatomic districts are used in a com-
bined way, to achieve an ideal correction of the defect
(Fig. 19) [1–23].
6 Local Anaesthesia with Sedation
In most cases, patients undergo local anaesthesia with seda-
tion; only in some cases, and in association with face liftings,
we use general anaesthesia.
The harvesting zones are infiltrated with a lidocaine 0.5 %
solution with adrenaline 1:200,000, which we obtain by
mixing 20 ml of lidocaine 5 % and 0.5 ml of adrenaline
1:1,000 in 80 ml saline [15].
In OR, the patient is monitored with electrocardiography,
its blood pressure and oxygen saturation; sedation is achieved
Facial Lipofilling
Fig. 18 Lipofilling of dorsum and apex of the nose, before and after
with midazolam (0.5 μg/kg) and propofol in continuous infu-
sion 4–2 mg/kg/h, evaluating the sedation level.
Using lidocaine 5 % (1.5–2 ml for each block) and a 25-G
needle, we block the infraorbital nerves for the inferior
orbito-palpebral malar region and nasal, upper lip and naso-
labial furrows; the mental nerves for lower lip, chin and man-
dibular contour; and the supratrochlear and supraorbital
nerves for the region of the superior palpebral orbital margin
and the forehead. Upper and lower eyelids are always infil-
trated with a local anaesthetic and vasoconstrictor solution,
with a 30-G needle, while we try not to infiltrate the other
areas, whenever possible, to avoid losing the landmarks and
altering the volumes to treat (Figs. 20, 21, and 22).
7 Complications
Postoperative hematoma usually is neither a relevant nor
a frequent complication, even with less infections. In the
1041
same way, asymmetry is not typical of lipofilling; usually
it is preoperative and it’s necessary to clarify with
the patient if and how it’s possible to correct that
asymmetry.
On the contrary, oedema is always present and in the early
2–3 weeks is quite apparent, as well as the ecchymoses. In
the eyelids, oedema can persist longer, and lymph drainage is
often prescribed to speed up the recovery.
Nervous lesions are quite uncommon, because in the dan-
gerous areas the blunt cannula prevents problems, and any
palsy normally resolves in 60 days.
In eyelids and lips it is necessary to avoid sequelae with
adipose tissue that can be felt and seen, due to a spaghetti-
like or “cocoon” injection. This is now avoided with the use
of much smaller and blunt cannulae.
Uncommon cases of fat embolism are reported and are
recommended to inject the fat tissue mainly in dangerous
zones while retracting the cannula, during the typical to and
fro movement of lipofilling.
1042 D. De Fazio and L. Barberi

Fig. 19 Lipofilling in facial atrophy, before and after

Facial Lipofilling 1043

Fig. 21 Mental nerve block

Fig. 20 Infraorbital nerve block

Fig. 22 Supratrochlear and supraorbital nerve blocks

1044
Informed Consent Form for Lipofilling Surgical
Procedure
Name: Surname……………………………………….
INFORMATION
Volume loss in some areas of the face, like zygoma and
cheeks, may traduce ageing or result from an excessive
weight loss; other bodily zones as well can be filled to
achieve a more harmonious contour, during a liposculp-
ture procedure. These depressions can be corrected in the
most natural and safe way by using the transfer of own fat
tissue.
Fat transfer, also called autologous fat graft or lipofilling,
restores the volume of face and body features with the
patient’s own fat and represents an alternative to other
treatments for filling.
• What is lipofilling?
• Face and body lipofilling is a natural, safe and not aller-
genic method to redraw your face and your body and can
increase the definition of zygoma, cheeks, chin and other
bodily zones like flanks and buttocks.
• Since this method uses your own cells, you will never
have an allergic reaction. With lipofilling, it’s possible to
extract the fat tissue aspiring it from zones like thighs or
abdomen, to transfer it in any region of the body. The
grafted fat stays in the treated areas.
Lipofilling can also correct posttraumatic or postsurgical
defects.
• How is lipofilling done?
Lipofilling is usually done ambulatory, since both
donor and receiving areas receive a local anaesthesia.
Using a small needle connected to a syringe, the fat is
harvested from the donor site, where the fat is more
compact, like the abdomen, buttocks or the internal
face of the thighs. Once aspirated, the fat is processed
to remove fluids in excess and then reinjected using a
thin cannula. This procedure can be repeated as needed,
to obtain the desired correction. The fat harvesting for
lipofilling is usually performed combined with other
procedures, including liposculpture or face rejuvena-
tion surgery.
• Which advantages does lipofilling offer?
– The transferred fat stays lifelong.
– There is no risk of allergy.
– The result is extremely natural.
D. De Fazio and L. Barberi
• What happens after the lipofilling?
After the procedure, the patients are immediately able to
perform daily activities. Some discomfort following the
procedure can be controlled with drugs. Oedema, which
can be marked particularly in the eyelids and lips for
7–10 days, and ecchymoses, which usually resolve in
7–10 days, are easily corrected with fard beginning at first
postoperative day, since there is no scarring. Results are
stable after the first month and are permanent.
• Possible complications
Oedema, hematoma, rare asymmetries, exceptional cases
of fat embolism and very rare nervous lesions
Informed Consent
After reading and understanding the above information, I
authorise Dr…..to perform the lipofilling procedure on
my person.
I authorise moreover further procedures which are deemed
necessary, in his judgement, to the success of the surgery
or for my health during the surgery and during the postop-
erative care.
The surgical risks and the potential complications have been
thoroughly explained to me.
I am aware that any surgical procedure, as many other acts of
daily life, like driving a car or travelling by plane, involves
certain risks, even deadly.
There are specific risks for a specific procedure and other
generic risks correlated to any surgical procedure, includ-
ing hematomas, infections, abnormal scarring, delayed
healing and sensitivity changes. All the surgical procedures
involve a scar. I understand that, while good results are
expected, these cannot be assured nor it’s possible to guar-
antee against any complication or unfavourable result.
To obtain the best possible result, some further procedures
can be necessary. If this would happen, it’s customary that
the operatory room expenses will be charged to the
patient, while the surgeon will not produce another bill.
I give my consent to taking photograph before and after the
procedure, for scientific or teaching purposes. It’s obvious
that my name will not be given in any case.
Patient’s signature…………. Surgeon’s
signature………….
Date…………..
Facial Lipofilling
Pearls and Pitfalls
The advantages of this technique are:
• There is no risk of allergy.
• The results are extremely natural.
• The transferred fat is permanent. The advantages of
these techniques are many: the lesser invasivity
thanks to the Coleman micro-cannulae, the absence
of rejection due to the fact that the used fat tissue
comes from the patient himself or herself and the
possibility to perform these procedures under local
anaesthesia in day surgery;
• Another great potential in this procedure is the
opportunity to repeat it every time it is desired to
increase the volume, when the results obtained with
the first session are not sufficient.
• Immediately after the procedure, the patients are
able to perform their daily activities.
• In eyelid lipofilling, it is recommended to use tissue
harvested with ultra-fine technique.
The disadvantages are:
• Possible swelling and redness in the treated zone
• The need sometimes to repeat the procedure two or
three times, to stabilise the results.
The disadvantage of this technique is on the contrary
due to the unavoidable resorption that in the first
3 months the 20–30 % of the grafted fat tissue under-
goes. In this respect, in the face it is recommended never
to overcorrect: grafting new adipose tissue is much easier
than removing an excess of it in these zones.
References
1. Avelar RL, Goelzer JG, Azambuja FG, De Oliveira RB, Pase PF
(2010) Use of autologous fat graft for correction of facial asym-
metry stemming from Parry-Romberg syndrome. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 109(2):e20–e25
2. Carraway JH, Mellow CG (1990) Syringe aspiration and fat con-
centration: a simple technique for autologous fat injection. Ann
Plast Surg 24(3):293–296
3. Coleman SR (2006) Structural fat grafting: more than a permanent
filler. Plastic Reconstr Surg 118(3 Suppl):108S–120S
4. Coleman SR (1997) Facial recontouring with lipostructure. Clin
Plast Surg 24:347–367
5. Coleman SR (1995) Long-term survival of fat transplants: con-
trolled demonstrations. Aesthetic Plast Surg 19(5):421–425
6. Coleman SR (2004) Structural fat grafting. Quality Medical
Publishing, St Louis
7. Coleman SR (2001) Structural fat grafts: the ideal filler? Clin Plast
Surg 28(1):111–119
1045
8. Guaraldi G, Bonucci, PL, De Fazio, D (2010) Autologous fat trans-
fer. Chapter 55. In: Shiffman MA (ed) Facial fat hypertrophy in
patients who receive autologous fat tissue transfer. Springer-Verlag.
Berlin-Heidelberg.
9. De Fazio D et al (2004) Autologous fat transfer for the treatment of
HIV-related face lipoatrophy: a long follow-up experience [Abstract
87]. In: 6th international workshop on adverse drug reactions and
lipodystrophy in HIV, Washington, DC
10. De Fazio D et al (2004) Long-term follow-up of graft hypertrophy
after autologous fat transfer for HIV-related face lipoatrophy (ham-
ster syndrome 1 year later) [Abstract 90]. In: 6th international
workshop on adverse drug reactions and lipodystrophy in HIV,
Washington, DC
11. Eder H (1997) Importance of fat conservation in lower blepharo-
plasty. Aesth Plast Surg 21(3):168–174
12. Fitzgerald R, Graivier MH, Kane M, Lorenc ZP, Vleggaar D,
Werschler WP, Kenkel JM (2010) Facial aesthetic analysis. Aesthet
Surg J 30(Suppl):25S–27S
13. Foyatier JL, Mojallal A, Voulliaume D, Comparin JP (2004)
Clinical evaluation of structural fat tissue graft (Lipostructure) in
volumetric facial restoration with face-lift. About 100 cases. Ann
Chir Plast Esthet 49(5):437–455
14. Loeb R (1993) Naso-jugal groove leveling with fat tissue. Clin Plast
Surg 20(2):393–400
15. Moore JH, Kolaczynski JW, Morales LM et al (1995) Viability of
fat obtained by syringe suction lipectomy: effects of local anesthe-
sia with lidocaine. Aesthetic Plast Surg 19(4):335–339
16. Moseley TA, Zhu M, Hedrick MH (2006) Adipose-derived stem
and progenitor cells as fillers in plastic and reconstructive surgery.
Plast Reconstr Surg 118(3 Suppl):121S–128S
17. Piasecki JH, Gutowski KA, Lahvis GP et al (2007) An experimen-
tal model for improving fat graft viability and purity. Plast Reconstr
Surg 119(5):1571–1583
18. Rohrich RJ, Joel E (2009) Chapter 29 - The subcutaneous fat com-
partments and their role in facial rejuvenation – Pessa. In: Coleman
SR, Mazzola RF (eds) Fat injection from filling to regeneration.
Quality Medical Publishing, Inc, St. Louis
19. Rohrich RJ, Sorokin ES, Brown SA (2004) In search of improved
fat transfer viability: a qualitative analysis of the role of centrifuga-
tion and harvest site. Plast Reconstr Surg 113(1):391–395
20. Schaverien MV, Pessa JE, Rohrich RJ (2009) Vascularized mem-
branes determine the anatomical boundaries of the subcutaneous fat
compartments. Plast Reconstr Surg 123(2):695–700
21. Shiffman MA, Mirrafati S (2001) Fat transfer techniques: the effect
of harvest and transfer methods on adipocyte viability and review
of the literature. Dermatol Surg 27(9):819–826
22. Sperber SM, Dawid IB (2008) Barx1 is necessary for ectomesen-
chyme proliferation and osteochondroprogenitor condensation in
the zebrafish pharyngeal arches. Dev Biol 321(1):101–110
23. Sterodimas A, Huanquipaco JC, De Souza Filho S, Bornia FA,
Pitanguy I (2009) Autologous fat transplantation for the treatment
of Parry-Romberg syndrome. Plast Reconstr Aesthet Surg
62(11):e424–e426
24. Szabo-Rogers HL, Geetha-Loganathan P, Nimmagadda S, Fu KK,
Richman JM (2008) FGF signals from the nasal pit are necessary
for normal facial morphogenesis. Dev Biol 318(2):289–302
25. Ten Cate AR (1998) Oral histology. Development and structure.
Mosby Inc, St Louis
26. Von Heimburg D, Hemmrich K, Haydarlioglu S et al (2004)
Comparison of viable cell yield from excised versus aspirated adi-
pose tissue. Cells Tissues Organs 178(2):87–92
27. Yoshimura K, Matsumoto D, Gonda K (2005) A clinical trial of soft
tissue augmentation by lipoinjection with adipose-derived stromal
cells. Presented at the International Fat Applied Technology Society
(IFTAS) third annual meeting, Charlottesville
28. Zoumalan RA, Larrabee WF Jr (2011) Anatomic considerations in
the aging face. Facial Plast Surg 27(1):16–22
 Cheiloplastics
Flavio Saccomanno
1 Introduction
From the very beginning, ancient civilizations have tried to
exalt the lips according to their cannons of beauty, by colour-
ing them or adorning them with ornaments. The lips mark
the exterior limits of the mouth, and, given their chewing,
speech, facial mime, sexual and aesthetic functions, are a
sophisticated anatomic entity. Form and volume may vary
according to ethnic origin within limits considered the norm,
liable, however, to change with the onset of old age.
Today, full, well-formed lips are universally recognized
as a sign of youth and sensuality. Aesthetic corrections of the
mouth must preserve its functions at all times, especially as,
like the eyelids, it guards a ‘place of identity’ of psychologi-
cal importance linked to the subconscious self-identification
of the individual.
When dealing with aesthetic correction, the surgeon must
evaluate the impact of his work on the physiology of the lips
carefully and preserve their function.
The demand for aesthetic correction of the lips has
increased over the years, mainly with regard to increasing
the volume.
The injection of filling materials is a relatively easy
method to use and gives immediate results which have made
it very popular.
The corrective efficacy of the fillers has reduced the indica-
tion for aesthetic surgery procedures. At the same time, there
has been an increasing demand for corrective surgery follow-
ing an excessive or inappropriate use of injected fillers.
Unaesthetic features of the lips may have congenital ori-
gin or be acquired later in life; in the latter case, ageing and
traumas are the most common causes (Fig. 1).
Advancing age together with genetic and environmental fac-
tors and habitual facial expressions are the most common causes
F. Saccomanno, MD
Private Practice, Rome, Italy
e-mail: flaviosac@tin.it
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_71
for the alterations in the morphology of the lips and in different
combinations affect everybody indiscriminately. The vermilion
loses its turgidness and the rima drops. The skin loses its elastic-
ity and the muscular adhesions slacken, resulting in the length-
ening of the upper lip and the lowering of the commissures. The
elevations of the crests and the contour are reduced with a con-
sequent flattening of the philtrum. The wrinkles around the
mouth become more pronounced (Fig. 1b) and make the whole
face appear old; consequently, a correction of the lips can
improve the appearance of the entire face.
Hence, surgical correction procedures, both in the young
and in the adult, aim at the restoration of proportions. These
procedures must be based on the strong aesthetic sense of the
surgeon and his perfect knowledge of the surgical anatomy
and the microscopic structure of the lips, keeping in mind
that these corrections are carried out at the level of individual
tissues. Corrections of any kind must respect the functions of
the lips.
Any surgical correction must consider the age of the
patient and the future consequences that these corrections
may have.
Doctors must not yield to abnormal requests; a patient has
the right to express his wishes, the surgeon has the obligation
to safeguard the patient and if necessary dissuade him.
Complications with irreversible outcomes, resulting from
the excessive injection of fillers, of sometimes even inappro-
priate materials, or incorrect surgical indications, are becom-
ing more and more frequent.
2 Anatomy
The lips of the mouth surround the entrance to the oral cav-
ity: they are mobile, horizontal when closed and have a
muscle-membranous structure. The anterior part of each lip
is made up of a cutaneous external covering, defined by a
clear dividing line, the contour, and continues into an inter-
mediate part of dry mucosa, the vermilion, which at its rear
1047
1048 F. Saccomanno

a b

Fig. 1 (a) Thin, long lip ‘congenital’. (b) Senile lip ‘acquired’.

is delimited by a transition line and in the posterior part

becomes the humid mucosa which internally lines the
vestibule. By means of the fornix of the vestibule the rear part
continues into the gums and is delimited by the mucus-gum
line. The mucosa of the fornix of the vestibule medially join
together creating a triangular fold attached to the gum,
known as frenulum of the lips which is always more devel-
oped in the upper lip.
The line of contact of the closed lips, the rima of the
mouth, is situated slightly above the cutting edge of
the upper incisors. Small dips, the labial commissures, mark
the corners of the mouth on both sides and are located
distally at the first premolar. The upper lip extends upward
to the nostrils and is delimited on both sides by the nasola-
bial folds. The median cutaneous part appears concave,
creating the subnasal sulcus under the nose or philtrum, and Fig. 2 A upper lip: 1 nasal sulcum or philtrum, 2 crests, 3 tubercle, 4
contour, 5 vermilion, 6 nasolabial fold, B lower lip: 5 vermilion, 7
convex in the vermilion giving rise to a protuberance, the
median fossette, 8 vermilion with its tendentially convex lateral parts, 9
labial tubercle. The philtrum is separated from the lateral labio-mental fold, 10 contour, 11 rima of the lips, C–C′, labial
portio by the crests which converge upwards, from the commissures
contour to the base of the columella.
The lower lip extends towards the chin, delimited by the
labio mental groove. There is a small dip or fossette on the
median line, below the contour line. The vermilion in the 3 Structure
median porzio, corresponding to the tubercle on the upper
lip, is slightly concave and the lateral porzios are flat or ten- The corrective operations on the lips act on the individual
dentially convex (Fig. 2). components of the tissues. In-depth knowledge of the
The shape, dimension and volume may vary according to structure of the lips as well as their morphology is essen-
race, and genetic features also have individual characteris- tial. The aesthetic evaluation of the lips focuses on the ver-
tics. Not many papers have been published on this topic: milion and any kind of corrective operation will modify it
Sawyer, See and Nduka have made an objective, 3D stereo- in some way.
photometric study of the Caucasian mouth, deducing param- Its structural peculiarity lies in the fact that it has a
eters that can be used as references. unique epithelium covering, which is not found in any
Cheiloplastics
Fig. 3 Sagittal section of the lips and the vestibule. 1 epithelium of the
labial mucosa, 2 labial glands, 3 labial arteries (coronary a.), 4 veins, 5
bundle of orbicular muscle, 6 submucosa and adipose tissue, 7 hairs and
sebaceous glands, 8 sudoriporous glands, 9 epithelium of the skin, 10
labial-gingival sulcus
other part of the body. This means that the surgeon has to
work with great care during any corrective operation as it
cannot be replaced. It is made up of a membrane of dry
mucosa and contains almost no glands, which allows the
underlying blood bed to show through, giving the vermil-
ion its characteristic red colour. It may be darker in tone
due to the greater presence of melanin, common in people
of black African origin.
The lips are made up of five strata, from the exterior
towards the interior. They are cutaneous, subcutaneous,
muscular, submucosa and mucosa (Fig. 3).
3.1 Cutaneous Strata
The skin is thick, very strong, adheres closely to the underly-
ing muscular fascia, rich in hair follicles and sebaceous
glands. It has a dense net of sensitive nerve endings and an
extensive superficial plexiform venous net.
In the adult male the contour of the lips is surrounded by
a beard (Fig. 3).
1049
3.2 Subcutaneous Strata
The subcutaneous strata is continuous with the face and is
made up of a more superficial aerolar strata, of lax connec-
tive tissue which contains numerous fat globules and a
deeper trabecolar strata which adheres to the muscular
system and penetrates into it. The laxness of these strata is
at the root of the oedema, with possible stretching and
deformation of the lips in the case of inflammation or local-
ized irritation (Fig. 3).
3.3 Muscular Strata
This is made up of a group of mime muscles that control the
mobility of the lips. The orbicular muscle of the mouth, the
only one with an occlusive sphincter function of the rima of
the mouth, makes up the greater part of the mouth and is an
almost elliptic shape.
The orbicular muscle surrounds the opening of the mouth
with the upper and lower extremities meeting at the commis-
sure of the lips. It is divided into two parts: the superficial
labial part, made up of scattered and lax muscular bundles
with dermic insertion and the deep marginal part, made up of
well-developed muscular bundles that adhere to the maxil-
lary and mandible bones. The deep marginal part makes up
the greater part of the muscle.
The extremities of other mime muscles that dilate the
rima are inserted in a radial manner in the orbicular mus-
cle; these are: for the upper lip – the elevator muscles of
the nasal ala, the elevators of the upper lip and the minor
zygomatic muscles; for the lower lip – the depressor mus-
cles of the lower lip and the tranversal muscles of the
chin; the greater zygomatic muscles, the elevator muscles
of the corners of the mouth, the depressor muscles of the
corners of the mouth, the pursing muscles and risorius
muscles for the lip commissures. Some of these muscles
have insertions in the cutaneous dermis and others deep in
the mucosa (Fig. 4).
3.4 Submucous Strata
The submucosa is made up of lax connective tissue with few
elastic fibres interspersed with numerous salivary glands, the
labial mucous glands, which look like small multiple nod-
ules set out in an almost continuous line and to the touch feel
like irregular, small, hard, protuberant nodules on the ves-
tibular side. Their ducts open directly into the oral vestibule.
Most of the blood vessels and sensitive nerve endings are
found in the submucous strata (Fig. 3).
1050 F. Saccomanno

Fig. 4 Upper lip: orbicular

muscle of the mouth (1), purses
lips forward; elevator muscles of
the nasal ala (2), elevator muscles
of the upper lip (3), raises the
upper lip and the nasal ala; minor
zygomatic muscles (4). Lower
lip: orbicular muscle of the
mouth (1), depressor muscles of
the lower lip (5), moves lower lip
down, turning it inside out;
mental muscle (6) and transverse
muscles, raise and pucker the
skin of the chin. Commissures of
the lips: greater zygomatic
muscles and elevator muscles of
the corner of the mouth (7), move
the lip fissure upwards, back and
lift lip fissures up; depressor
muscles of the mouth (9),
buccinator muscles (10), move
lip fissures backwards and make
the cheeks and the lips adhere to
the dental arches; risorius muscle
(8), move the lip fissures back

3.5 Mucous Strata

The mucosa is humid and made up of nonkeratinized strati-

fied squamous epithelium without the muscolaris mucosae.

4 Vessels, Nerves and Lymphatic Vessels

4.1 Arteries

The lips are principally vascularized by the upper and lower

labial arteries, branches of the face arteries that run along the
commissure level, and are set out around the oral orifice.
Secondary vascularization is provided by the infra orbital
and buccal arteries (branch of the maxillary artery), the
transverse artery of the face (branch of the superficial tempo-
ral artery) and submentum artery (branch of the face artery).
The arteries run through the lips between the muscular
and mucous strata at the level of the free margins anastomos-
ing with the arteries of the opposite side in the median line
making a complete arterial circle (upper and lower coronary
artery) (Fig. 5).
4.2 Veins
The venous drainage follows the passage of arterial vascu-
larisation and the tributary veins converge below the facial
and submentum veins.
Fig. 5 Section of the skin and the orbicular muscle. 1 right and left
upper labial arteries which anastomose medially (upper coronary
artery), 2 right and left lower labial arteries which anastomose medially
(lower coronary artery)
Most of the small veins form plexuses that circulate in
the subcutaneous layer. The absence of valves in the facial
vein means that if the flow in the veins is inverted it can
drain into the pterygium plexus through the transverse
vein of the face and into the cavernous sinus through the
angular and the ophthalmic vein. This fact explains one of
the most serious complications that can arise from a prop-
agation of inflammatory/infective processes of the face,
namely, the infection and thrombosis of the cavernous
sinus.
Cheiloplastics
Fig. 6 A submandibular lymph nodes, B submental lymph nodes. 1
lymphatic drainage from the mucosa and the skin of the upper lip, 2
cutaneous drainage of the median part of the lower lip, 3, 4 mucosa
drainage of the lower lip, 5 cutaneous drainage of the lower lip, which
cross over the median line and go to the submandibular lymph nodes of
the opposite side
4.3 Lymphatic Vessels
The lymphatic vessels of the upper lip surround the labial
commissures and together with the ones on both sides of the
lower lip drain into the sub-mandibular lymph nodes. The
ones in the centre of the lower lip run down the chin and
drain into the sub-mental lymph nodes. Some of the more
medial vessels may cross the median line unifying the drain-
age system of the two sides. There may be some small buccal
lymph nodes in the passage from the lower lip and the chin.
The sub-mandibular and sub-mental lymph nodes drain into
the deep cervical lymph nodes such as the pre-tracheal or
jugular-omohyoid (Fig. 6).
4.4 Nerves
Sensitive innervation for the upper lip is mainly provided by
the infra-orbital nerve (branch of the maxillary nerve) and
by the mental nerve for the lower lip. These nerves pass
through the corresponding foramens and make their way
towards the lips where they form small fan-like branches
1051
Fig. 7 Sensitive innervation: 1 infra-orbital nerve, branch of the maxil-
lary nerve of the upper lip, 2 mental nerve, branch of the mandibular
nerve for the lower lip. Pass through the corresponding foramens and go
towards the lips, 3 facial nerve branch
which spread over the whole surface of the lips. The anaes-
thetic blocking of these nerves makes a complete analgesia
of the lips possible (Fig. 7).
Motor innervation is provided by the facial nerve
through its zygomatic, buccal and marginal mandibular
branches.
5 Classification
The unaesthetic feature of the lips may be congenital, pres-
ent in the youth as a genetic characteristic, and/or acquired,
and present in the adult with advancing age. They can be
worsened by various factors: genetic, such as the hyperactiv-
ity of facial mime; environment, such as exposure to the sun;
and habit, such as smoking. Both, the young and the old may
acquire an alteration due to accidental or iatrogenous
trauma. The features may manifest themselves singly or
combined. The most frequent are: hypoplasia/hypotrophy,
insufficient projection of the lip contour and the philtra
crests, long upper lip, perioral wrinkles and the results of
former treatments (Table 1).
1052
Table 1
Inestetismi = Unaesthetic
Iperlasia = Hyperplasia
Ipoplasia/Ipotrofia = Hypoplasia/Hypothrophy
Vermiglio insufficiente = Insufficient vermilion
Contorno e creste poco definite = Poorly defined contour and philtra
crests
Labbro lungo = Long lip
Rughe peribuccali = Perioral wrinkles
Giovane = Young
Congenite = Congenital
Caratteristica familiare = Family characteristics
Esito traumatico accidentale/iatrogeno = Outcome of accidental/
iatrogenous trauma
Adulto = Adult
Acquisite = Acquired
Fattori = Factors
Eredo-familiare = Hereditary-familiar
Attitudinale = Aptitude
Ambientale = Ambient
Invecchiamento = Ageing
6 Anaesthesia
Anaesthesia must be performed after the planning of the sur-
gical procedure, as the shape and volume of the lips may be
altered making any kind of intervention unfeasible. This par-
ticular anatomical area lends itself to trunkal anaesthesia
which needs to be supported by a local anaesthetic which
also serves a haemostatic purpose. Four millilitre of lido-
caine at 2 % with adrenalin in a concentration of 1:200.000
is enough to completely block each lip. One millilitre of
anaesthetic is infiltrated per side, close to where the infra
orbital nerves emerge for the upper lip and the mental nerves
for the lower. In addition, 2 ml are infiltrated in each lip
locally distributing the solution between the vestibule and
the cutting line.
The use of a 1 ml syringe and a 2 cm 25G needle makes it
easier to distribute the solution in small doses. To distribute
the local anaesthetic evenly, the lip should be massaged
while the adrenalin takes effect. This method allows a com-
plete analgesia and good vaso-constriction with a minimum
change in the volume and shape making the corrective opera-
tion easier and more precise.
Other local anaesthetics can be used, for example prilo-
caine 0.5 %, mepivacaine 0.5 %, bupivacaine 0.25 %.
The local anaesthetic can be combined with vigilant seda-
tion advisable for excitable patients or when operating on
both lips at the same time.
F. Saccomanno
Table 2
Cheiloplastica = Cheiloplastica
Additiva = Additive
Riduttiva = Reductive
Volume = Volume
Rivestimento = Skin covering
Fillers = Fillers
Innesti = Grafts
Impianti = Implants
Vermiglio = Vermilion
Resezione = Resection
Contorno = Contour
Labbro lungo = Long lip
Derma = Derma
Adipe = Fat
Altri = Others
PTFEe = ePTFE
Altri = Others
V-Y = V-Y
7 Surgical Technique
The corrective procedure must be based on a careful objec-
tive, systematic examination that takes into account the dif-
ferent variables. The wishes and comments of the patient,
best expressed in front of a mirror, are very important and
help the surgeon understand his expectations. The shape,
volume, consistency, length of upper lip, perioral wrinkles
and any static and/or dynamic asymmetry must be observed
together with the patient and photographed. This will help in
the programming phase and the post-operative check-up.
The patient must be told what is feasible and what is not; he
must be informed of the kind of correction that he is under-
going and the post-operative course. After the operation, the
lips may swell up considerably, due to their intrinsic ana-
tomical structure and the type of operation. The patient may
not recognize himself during this period of temporary change
and needs to be prepared for it.
Corrections may be performed singly or combined with
others and essentially consist in the use of different proce-
dures: filling, lifting of the upper lip, eversion/inversion of
the vermilion and can be separated into two groups: additive
chieloplastic or reductive chieloplastics. Both involve the
structural elements of the content, i.e. volume (sub-mucosa,
the annexes and muscles) and the covering (skin and/or
mucosa). In additive chieloplastics some filling materials
may be introduced by means of injection (fillers) and others
as a graft or implant inserted with a surgical procedure
(Table 2).
Cheiloplastics 1053

8 Additive Cheiloplastics
8.1 Volume
8.1.1 Fillers
The advent of ‘fillers’ and the ‘laser’ has greatly reduced the
indication of surgical correction of the lips.
‘Fillers’ have a primary indication for volume and the
definition of the contour of the lips and the crest of the phil-
trum. Fillers introduced by means of injections are more ver-
satile, and permit a focused volume correction with more
predictable and immediate results (Fig. 8).
Though the operation is relatively simple, nevertheless it
requires rigorous and meticulous preparation by the doctor.
The type of or excessive and at times inappropriate use of
injected filler materials can result in complications that may
be difficult to solve with sometimes irreversible results and
permanent damage (Fig. 9).
The laser, used in the correction of the wrinkles around
the mouth and the improvement of the cutaneous quality,
substitutes dermoabrasion and chemical peeling.
These procedures are not dealt with in this chapter as they
are not considered surgical procedures.
8.1.2 Graft and Implant
The use of autologous and alloplastic materials in the correc-
tion of lip volume necessitates a surgical procedure which
makes this treatment more complex and in the long term
results do not always compensate unaesthetic features, the
reason why currently the use of fillers is more common. The
use of autologous tissues such as derma and fat is the sur-
geon’s first choice. The use of other tissue samples such as
the temporal fascia and the orbicular muscle may be consid-
ered convenient harvests when they can be obtained during
other operations. However, all tissues have varying resorp-
tion capacities which may at times reach 100 %; hence, they

a b c

Fig. 8 Immediate variation of the volume of the upper lip in relation to the quantity of infiltration with jaluronic acid of medium density. (a) Pre-
treatment. (b) After infiltration of half an ampoule. (c) After infiltration of one ampoule

a b

Fig. 9 Fibrotic nodules due to recurrent inflammatory processes after infiltration of ‘Bioalcamid’. Irreversible result with permanent damage
1054
a b
Fig. 10 (a) With the passing of time, the EPTFe thread placed in the contour may shift and become evident during extreme mouth movement.
(b) Explant via a small incision in the vermilion
have to be slightly hyper-corrected. Experience shows that
the derma is more stable and is obtained from a strip of skin
without epithelium with adhering adipose tissue. The sample
should preferably be harvested from an area that is not too
exposed where the derma is thick, as for example the inside
of the buttock fold. It may also be obtained during another
surgical procedure with exeresis of the skin. With the passing
of time, dermic cysts may appear in the grafted area, though
this is rare.
Irrespective of the tissue that is used, a possible revision,
to restore the reabsorbed volume, always involves another
surgical procedure and in any case cannot guarantee the
long-term stability of the result. This has induced researchers
to look for a substitute synthetic material with the following
characteristics: biocompatibility, physical-chemical inertia,
inalterability and reversibility, allowing an explant without
leaving any after-effects. Expanded Poli-Tetra-Fluoro-
Etilene (PTFEe) comes closest to these requirements.
Furthermore, it integrates into the surrounding tissue without
forming capsules making it more resistant to infection. The
final result of the correction with PTFEe directly depends on
the thickness of the implant, and is therefore more predict-
able than when using autologous tissues. The disadvantage
of PTFEe is that it may shift after a few years and at times be
perceptible to the touch and visible in certain extreme lip
movements (Fig. 10).
All these factors have made it fall into disuse. Nevertheless
PTFEe is still indicated in some cases, when only an increase
in volume is required or when the correction is modest and
does not have great aesthetic pretensions. Today, it is avail-
able as a 1–2 mm thick lamina, from which a lip-length
ellipse is obtained. This ellipse must be cut into parallel
1 mm strands that remain united at the two extremities. This
F. Saccomanno
prosthesis is then inserted into the subcutaneous of the ver-
million between the transition line and the contour by means
of a cannula needle. The volume depends on the number of
strands (Fig. 11).
Two 2–3 mm incisions are made at the two extremities of
the transition line and a cannula needle of about 5 mm is
introduced at a subcutaneous level, in the space between the
transition line and the lip contour. Two 2/0 nylon threads are
fastened to the extremities of the material to be inserted, and
one end of the thread is pulled right through to the other end
of the cannula, and the material is pulled into the cannula,
which is pulled out and the material remains in the subcuta-
neous (Fig. 12).
The lip is stretched bilaterally so that the material is
spread out and only then is the lateral excess material cut off.
It is important to place/push the extremities of the implant
deep enough to stop them from coinciding with the cutane-
ous incisions in order to prevent decubitus (Fig. 13)
The same technique may be used to insert derma and the
temporal fascia. They must be cut into ‘small bands’ into the
desired length and grafted with the same procedure used for
the PTFEe implant.
This method of insertion makes it possible to position the
graft or implant in a uniform level, and if necessary, permits
its removal and reinsertion to adjust the volume during the
procedure (Figs. 14 and 15).
The grafting of adipose tissue is also carried out by means
of a cannula needle but only one lateral insertion cut is made
in the transition line. The adipose donor areas are mainly
hypogastric or trochanteric. The size of the cannula needle
depends on the method chosen to treat the fat (a) washed,
filtered, decanted (Fig. 16) or (b) separated by centrifugation
according to Coleman; in the former, the needle size is
Cheiloplastics 1055

a b

Fig. 11 (a) a 1–2 mm thick lamina cut into parallel strands of 1 mm which remain joined at the two ends. (b) The prosthesis is inserted in the
subcutaneous layer between the transition and the contour lines. The volume depends on the number of strands

Fig. 12 (a) 2–3 mm incisions

a
at the extremity of the transition
line and insertion of a 5 mm
cannula needle in the
subcutaneous layer. (b) The
material (PTFEe) is drawn into
the cannula. The same method
can be used for inserting grafts

3 mm, in the latter 2 mm. In our experience, the fat treatment
method does not affect uptake. The Coleman method allows
a more accurate treatment of the projection of the contour
and the philtral crests.
The cannula needle, connected to a 3 or 2 ml syringe, is
inserted into the space between the transition line and the lip
contour, the same as for the graft/implant (Fig. 11b), always
at the subcutaneous level and the tissue is injected as the
needle is withdrawn, continuously checking the volume,
until a slight hypercorrection is obtained. Experience shows
that despite hypercorrection, re-absorption is high in the first
6 months, probably due to the great mobility and vascular-
ization of the lips (Fig. 17). No infiltration is carried out at
the intramuscular level as, in our opinion, the different levels
should be respected.
In some patients undergoing chance post-surgery check-ups
some years after their lipo-filling operation, the volume has
remained surprisingly stable, and a marked improvement of the
quality of the skin and the peribuccal wrinkles can be observed.
According to current studies, this may be due to the activities of
the staminal cells. The answer to this hypothesis can only be
provided by the researchers who study this topic (Fig. 18).
8.1.3 ‘V-Y’ Eversion
The techniques of ‘V-Y’ eversion can be used indifferently
for the upper and the lower lips for aesthetic ends or to
1056 F. Saccomanno

a d

e
b

Fig. 13 (a) The lip is stretched bilaterally so that the implant/graft is spread out. (b, c) The lateral excess is cut and the threads remain free and
their ends must not coincide with the cuts in order to avoid decupitus. (d) Graft. (e) Immediately after the operation

Fig. 14 (a, b) Implant of

PTFEe, pre- and post-surgery at
a b
12 months, volume and contour,
permanent and reversible result

correct asymmetries. They make it possible to obtain an
eversion of the vermilion, increasing the width of the vermil-
ion without a real volumetric increase, which one would
obtain with filler materials (Fig. 19).
In 1992, Aiache AE describes twofold ‘V-Y’ with plica-
tion of the muscles to increase the volume. We use a triple
V-Y for the upper lip and a single one for the lower lip, with-
out involving the muscles, using if necessary filler materials
to increase the volume, in the same sitting or 6 months after
the operation when the fibrosis of the healing process has
disappeared. In the younger patient, eversion also appears to
obtain an increase in volume due to the greater turgidness of
the subcutaneous layer (Fig. 20).
As for the upper lip, before local infiltration, reference
lines must be drawn and maintained throughout the whole
operation (Figs. 21 and 22): the transition line marks the pas-
sage between the dry exterior surface and the humid one of
the vermilion; the median line goes from the contour line to
Cheiloplastics 1057

a b

Fig. 15 (a, b) Dermic graft pre- and post-surgery at 12 months

a b

c d

Fig. 16 (a) Taking a sample from the trochanteric region. (b) Decantation. (c) Transfer into a 3 mm syringe without any contact with the exterior.
(d) Syringe with cannula needle ready for infiltration

the frenulum in the vestibule, and two lateral lines incorpo-
rate the tubercle. Three contiguous triangles are traced with
the transition line as their base and the vestibule as their
apex. The base of the central triangle must fall into the space
delimited by the intersection with the lateral lines and the
lateral triangles must be smaller in order to maintain the pro-
portion. The planning procedure is completed by drawing
two further external lines on the vermilion, starting from the
extremity of the bases of the two external triangles, from the
transition line towards the contour line. As far as the apexes
of the triangles are concerned, the central one must reach the
frenulum and the lateral ones must be shorter. The heights of
the triangles must be such that the ‘V’ can slip into the ‘Y’.
The size of the lower closing line of the V in the Y shows the
extent of the advance and therefore of the increase in the
surface of the vermilion which is everted.
1058 F. Saccomanno

a b

c d

Fig. 17 Upper lip: evolution of lipofilling over 6 months. (a) Pre-surgery. (b) Post-surgery of lipofilling of 2 ml at 1 month. (c) Post-surgery at
3 months. (d) Post-surgery at 6 months

a b c

Fig. 18 (a) Pre-surgery with a non-permanent tattoo of the contour to correct hypo-pigmentation. (b) Post-surgery at 6 months after lipofilling of
2 ml in upper lip. (c) Post-surgery at 6 years, in addition to the stability of the volume an improvement in the peri-buccal wrinkles can be observed
Cheiloplastics
a b
Fig. 19 (a) Pre-surgery of asymmetrical upper lip due to trauma. (b) Post-surgery at 6 months. (c) Post-surgery at 12 months
Fig. 20 V-Y upper lip. (a, b) Pre- and post-surgery at 6 months of an
elderly patient. (c, d) Pre- and post-surgery at 6 months of young patient
The same planning procedure is used for the lower lip, but
there is only one central ‘V’ and the lateral lines are positioned
more externally, at the edge of the fossettes. A single triangle
with lateral back cuts is traced (Fig. 22). The base of the lower
triangle is larger than the base of the central upper triangle.
Start the infiltration process to obtain analgesia and
haemostasis.
The incisions are made along the lines that mark the sides
of the triangles and at the level of the vermilion, along the
lateral and external lines, stopping a few millimetres from
the contour (Fig. 21b). The incision must be orthogonal and
cut through the full thickness of the mucosa down to the
muscular layer. The dissection, directly above the muscular
level, involves the whole area delimited by the incisions.
The dissection at the level of the transition line must always
1059
c
be very precise as the labial arteries meet there and are
skeletonized.
After careful haemostasis, proceed with the advancement
of the vermilion with suture. Slipping the triangles upwards
you start by closing the lower parts of the ‘Y’ of the central
triangle, proceeding at the same pace with the lateral trian-
gles. Sometimes, in proportion with the extent of the
advancement, the incisions on the vermilion may have to be
extended to the contour line. The size of the lower closing
stroke of the V in Y shows the extent of the advancement and
therefore the increase in the surface of the vermilion which is
everted (Fig. 21c). Twisted thread preferably rapid resorp-
tion 4/0 is used for the suture and should be removed after
about 5–6 days. The increase in the vermilion, obtained with
the triple ‘V-Y’ is rewarding; the results are stable and the
scars are invisible. The patient must be informed that he will
suffer from temporary hypaesthesia (Figs. 23, 31, and 32).
9 Reductive Cheiloplasty
9.1 Contour
In 1957, Gilles and Millard described an incision, modified by
Meyer in 1976, along the contour of the upper lip with the resec-
tion of an ellipse of skin by means of another cut higher up. The
incision goes down to the muscular level and suture is carried out
without skin undermining. The lip height is reduced and at the
same time the vermilion is lifted and any perioral wrinkles are
removed. A scar at the level of the lip contour remains (Fig. 24).
Similar results can be obtained with the ‘lip lift’ where the
scars are better hidden, as will be seen later.
In 1991, writing about the ‘corner lift’, Austin describes the
resection of a triangle of skin carried out above and laterally to
the commissure of the lip. With the suture the corner of the com-
missure is lifted and pointed upward. The results seem to be
stable and the scar of good quality, located in the end part of the
lip contour prolonged toward the exterior (Fig. 25). Later,
Austin and Weston managed to confine the scar to the commis-
sure, involving, however the whole corner of the lip.
1060
a a
Fig. 21 (a) Reference lines: 1 the transition line, 2 the median line from
the contour to the vestibule, 3 two lateral lines to the Cupid incorporating
the whole tubercle; showing 3 contiguous triangles a, b, c with the transi-
tion line as the base and the apexes towards the vestibule; 4 external lines
that start from the extremities of the bases of the two external triangles
and go from the transition line towards the contour. (b) Incision line. (c)
The closure of the V in Y indicates the extent of the advancement and
therefore the increase in the surface of the vermilion which is everted
The tissue structure of the labial commissures is very
delicate and thus placing a scar, for aesthetic ends, in a
corner which is often humid and mobile must be evaluated
F. Saccomanno
Fig. 22 Planning of surgical procedure of V-Y. (a) Lower lip: one cen-
tral ‘V’, 1 Lateral line, 2 Back-cut, (b) Final suture
with great care. Any, even if reduced, possibility of dehis-
cence or hypotrophy could have serious consequences
(Fig. 26).
9.2 A Long Lip: Lifting of the Upper Lip
This essentially consists in the exeresis of a cutaneous ellipse
on the upper part of the lip below the nostrils (Fig. 27).
The shortening of a long lip, first proposed by Cardoso
and Sperli in 1971, Gonzales-Ulloa in 1979, later by
Rosner and Isaac in 1981 and Austin in 1986, is perhaps
the most gratifying aesthetic lip operation. The correction
of the length of the upper lip confers a significant, at times
gaudy aesthetic improvement of the face, immediately per-
ceptible after the operation and permanent. Moreover, the
contour is also improved and appears less flat, due to lift-
ing, and an augmentation of the vermilion, due to eversion
(Fig. 27).
Cheiloplastics 1061

a b c

d e f

Fig. 23 (a, a′) Pre-surgery of augmentation of the surface of the vermilion with V-Y. (b, b′), Immediate post-surgery. (c, c′), Post-surgery at
6 months

a b

Fig. 24 (a) Incision and exeresis of cutaneous ellipse at full thickness along the contour of the upper lip. (b) Raising of the vermilion with the
removal of any perioral wrinkles and contemporaneous reduction of the length of the lip and eversion of the vermilion

A standard superior incision line is planned, which enters
the nostrils in a ‘V’ shape from the nasal ala furrows and
surrounds the juncture of the columella. This fragmentary
placing of the cutting line is essential for the quality of the
scar which is usually invisible.
The final shape of the contour line of the lip depends on
the shape and the positioning of the lower cutting line,
which is variable. It may be a specular image of the upper
line if no change to the shape of the lip is desired; an accen-
tuation of the central concavity will further accentuate
1062
a b
Fig. 25 (a) Resection of a triangle of skin carried out above and laterally of the commissure of the lip. (b) With the suture, the corner of the com-
missure is raised giving it an upward lift
Fig. 26 Resulting scar along
the contour of the upper lip
and commissure, often with
a tattoo to make it less visible
Cupid’s bow; by accentuating the lateral concavities a mod-
est improvement of the third exterior of the lip may be
obtained (Fig. 28). The drawing is completed with three ver-
tical reference lines: a median line and two lateral ones
which descend vertically from the apex of the ‘V’ of the
nostrils towards the crest. These must be maintained
throughout the entire operation (Fig. 29a).
The extent of the correction depends on the positioning of
the lower line of the ellipse. The lower the line, the greater
the effect on the increase of the vermilion and the aesthetics
of the face. The exeresis of a 5–6 mm cutaneous ellipse is
F. Saccomanno
never excessive and hence may be a good starting point in
attempting this technique.
The previously traced cutaneous ellipse is cut to the muscu-
lar layer and is separated from the muscular plane (Fig. 29b).
The musculature is plicated with a 3/0 re-absorbable twisted
thread starting with sutures at the median and lateral lines. The
tension must be completely unloaded with the suture of the
deep derma with a 4/0 thread of the same material and the per-
fectly adjoining skin margins may be sutured with a 6/0 mono-
filament nylon thread to be removed on the fifth day (Fig. 29).
A thin layer of antibiotic cream is applied and the wound is left
Cheiloplastics
a b
Fig. 27 (a) Long upper lip. (b) Exeresis of a cutaneous ellipse above the lip. (c) Shorter lip with improved contour which is less flat due to suspen-
sion (lifting) and also an increase in the vermilion due to eversion
a b
Fig. 28 Standard superior incision line (a–c), which enters the nostrils
in a ‘V’ shape from the nasal wing furrows and encloses the juncture of
the columella. Variable lower lines. (a) Specular lower line does not
a b
Fig. 29 (a) Surgical procedure plan with: 1 median line of the lip, 2
two lateral lines that descend vertically from the apex of the ‘Vs’, 3
Standard superior incision line, 4 Variable lower line specular to the
upper one which does not alter the shape of the contour (C). (b)
uncovered. The patient is instructed in the daily asepsis. No
antibiotic therapy is required.
The local oedema, usually of minor importance, migrates
gravitationally towards the vermilion augmenting its
volume, a fact usually welcomed by patients who must be
1063
c
c
modify the shape of the contour. (b) More concave shape in the central
porzio everts the area of the tubercle of the vermilion. (c) Completely
concave lower line moderately models a flat contour
c
Cutaneous exeresis of full thickness. (c) Margins without tension which
is offloaded in the sutures of the muscular plications and the deep derma
making outcome stable
warned so that they are not disappointed in the post-
operative period.
The indication of the lip lift is the reduction of the long
lip, not increased volume which may just be an associated
feature (Figs. 30, 31, 32, and 34).
1064 F. Saccomanno

Fig. 30 Correction of senile

long lip maintaining contour a b
shape. Pre- and post-surgery at
6 months

Fig. 31 Senile long lip, flat and

a b
asymmetric contour line with
insufficient vermilion; Post-
surgery at 3 months after lip lift
and V-Y correction of the upper
and lower lips

Fig. 32 (a) Lip length in the

a b
norm but patient unsatisfied with
the shape of the contour line,
emphasized by lipstick and
insufficient vermilion. (b)
Post-surgery at 3 months of
correction with lip lift and V-Y
of the upper lip
Cheiloplastics
9.3 Reduction of Volume
Corrective aesthetic interventions more often than not aim at
the reduction in volume, as in hyperplasia of genetic origin,
most common in people of black African origin. The last
decade has seen an increased demand for reductive surgical
interventions of an iatrogenous origin due to the increased
and often inappropriate use of injected filler materials.
In both cases, the correction technique is the same and
usually consists in the exeresis of an ellipse of mucosa and
submucosa which can vary in size and location.
The amount of the tissue to be removed must be planned
prior to local infiltration and is a matter of intuition; under
correction is preferable to overcorrection. The patient must
be aware of the fact that insufficient reduction may be revised
while an excessive reduction is irreversible.
It is essential to have precise and stable reference points
that aim at a symmetrical result, irrespective of the extent of
the reduction. That is the purpose of tracing the median line
which goes from the contour to the frenulum and the transi-
tion line; they will serve as a reference in programming the
quantity of the excess tissue to be resected. They must be
perpendicular to each other at the end of the operation.
The suture is carried out with a rapidly re-absorbing
twisted 4/0 thread, which is removed on the fifth day; other-
wise, it may become incorporated in the mucosa (Fig. 33).
A chlorhexidine-based collutory is applied 3 days before
the operation and antibiotics are prescribed after the opera-
tion (Figs. 34 and 35).
10 Informed Consent
The consensus form is a document where the patient declares
that he has understood the information he has received during the
consultation and the pre-operative talk regarding the characteris-
tics of and the risks inherent in the programmed surgical opera-
tion. After having carefully read and discussed each unclear term
with the surgeon, the patient signs the form as a confirmation.
The different surgical corrective procedures used are not
covered by a single general consent form. Information rela-
tive to all procedures to be communicated to the patient fol-
low, but the specific information must be added by the
individual surgeon.
10.1 General Information
• The operation will take place in the surgery under local
anaesthetic or in ‘Day Surgery’ when associated with
sedation, depending on the type of correction and the
clinical condition of the patient.
1065
• The frequency of the medication, timing of the removal of
the stitches depend on the individual clinical case.
• The results become satisfactory only after the acute
oedema period, which lasts some days, and in the lip, irre-
spective of the correction undertaken, the swelling is
always significant due to its rich vascularization and
mobility.
• The oedemas and ecchymosis usually disappear within a
month but may persist in reductive surgical procedures
due to excessive volume after the infiltration of fillers
where the lymphatic drainage system often turns out to be
insufficient.
• In the post-operative period, tension may be felt, espe-
cially during mouth movement, but this abates within a
few days.
• Sensitivity may remain altered for varying periods.
• The operation will necessarily leave scars. The permanent
scars on the skin depend on the type of correction and are
not perceivable as they are well camouflaged by their
location, but their evolution also depends on the skin type
and in the third month after the operation may appear
hypertrophic and will stabilize around the sixth month
and the colour will become normal in time. This phenom-
enon is rare in the scars in the vermilion and the mucosa.
• Specular symmetry of the hemilips is impossible, and in
the case of reductive cheiloplasty as well as in the other
procedures, a subsequent operation may be necessary for
further improvements.
• As surgery is not an exact science, it is not possible to
plan a precise result, in as much as the deep healing pro-
cesses do not only depend on the surgical techniques
applied but even more so on the response of the organism.
As in all operations complications may arise, such as
oedemas, sieromas and infections.
• The patient must enclose a written consent to be photo-
graphed before, during and after the operation, as clinical
documentation, which the surgeon will only use in a sci-
entific context guaranteeing complete anonymity.
10.2 Before the Operation
• Inform the surgeon of any treatment with medicines
(especially cortisone, contraceptives, hypoglycemic, anti-
biotics, tranquillizers, sleeping pills, stimulants, etc.).
• Stop taking any drugs containing acetylsalicylic acid (e.g.
Alka Seltzer, Ascritptin, Aspirin, Bufferin, Cemerit, Vivin
C) or other non-steroid anti-inflammatory drugs.
• If female, inform the doctor of the menstrual cycle.
• Eliminate or reduce cigarettes for at least 1 week before
and after the operation.
1066 F. Saccomanno

a b

c d

e f

Fig. 33 Reduction of volume with inversion of lower lip. (a) median line mucosa and the sub-mucosa with the infiltrated material. (e) Suture with
of lip from the contour to the frenulum, 2, transition line which in this reabsorbable 3/0 twisted thread. (f) Post-surgery at 10 days. (Continued
case coincides with one of the sides of the ellipse to be resectioned. (b, c) on following page) (Continuation) (g–j) Pre- and post-surgery at
Incision to the muscular plane. (d) Muscular plane after exeresis of the 6 months. (k, l) Observe the reduction and inversion of lower lip
Cheiloplastics 1067

g h

i j

k l

Fig. 33 (continued)
1068 F. Saccomanno

a b

c d

Fig. 34 (a, b) Pre- and post-surgery of lips excessively infiltrated with and the upper lip to maintain the projection of the contour; in addition
silicone. (c, d) Pre- and post-surgery of the same patient at 12 months to reductive surgery, a compensatory lip lift was also carried out
after volume reduction of the lips. Observe the inversion of the lower lip
Cheiloplastics 1069

Fig. 35 (a) Excessive

a b
infiltration of non-specified
material with consequent
asymmetry of upper lip. (b)
Post-surgery of one-sided
reduction with symmetrical
arrangement at 12 months

• Immediately inform the surgeon of the onset of a cold, 10.5 After the Operation
sore throat, cough, etc.
• Use a chlorhexidine-based collutory starting 3 days before
the operation, if the oral cavity is involved in the surgical • On dismissal, make sure someone is there to take you
procedure, following the mode and dosage specified in home.
the prescription. • No sport activities or gymnastics for a month.
• Avoid exposure to direct sunlight or intense heat (e.g.
sauna, UVA lamps).
10.3 The Day Before the Operation • If the procedure involved the oral cavity, use
chlorhexidine-based collutory for 3 days after the opera-
tion, following the mode and dosage of the prescription
• Do not eat or drink for 7 h prior to the operation if seda- given you upon dismissal which also includes an antibi-
tion is planned. otic therapy.
• Remove the nail varnish on the index finger of one hand. • At the least doubt of an abnormal post-operative course or
for any other problem connected to the operation, consult
your surgeon.
10.4 The Day of the Operation

• Maintain fast and wear a shirt/dress with buttons/zip all

the way down the front.
 Part IX
The Face: Non-surgical Treatment
 Botulinum Toxin: BOTOX®
Ina A. Nevdakh, Bryant A. Toth, and Stephen P. Daane
1 History
Botulinum toxin type A (“BOTOX®,” Allergan Inc., Irvine
CA) [1] was first quantified and used clinically by ophthal-
mologist Dr. Alan B. Scott [2] of San Francisco, California.
Dr. Scott published the first reports using Botulinum toxin
type A for the treatment of blepharospasm, strabismus, and
glabellar frown lines in the early 1980s. The FDA approved
BOTOX® in December 1989 as an orphan drug for the treat-
ment of strabismus, hemifacial spasm, and blepharospasm.
Since its FDA approval for glabellar frown lines in 2002,
BOTOX® has had widespread popularity in the nonsurgical
treatment of crow’s feet, transverse forehead lines, lipstick
lines and platysmal bands, as well as migraines, axillary
hyperhidrosis (FDA approved in 2004), facial paralysis,
hidradenitis, torticollis, and spasticity in cerebral palsy. It is
also indicated for general surgery in cases such as anal fissur-
ing and esophageal spasm. Today, many commonly performed
cosmetic procedures that use BOTOX® are “off label” [3].
2 Mechanism of Action and Structure
There are different serologically distinct botulinum neuro-
toxins, A, B, Cα, Cβ, D, E, F, and G that are produced by
various strains of a gram positive, anaerobic, rod-shaped
bacterium called Clostridium botulinum. Types A, B, E and,
rarely, F and G are associated with human botulism [4].
I.A. Nevdakh, MD
Department of Plastic Surgery, Oregon Health Sciences University,
Portland, OR, USA
B.A. Toth, MD, FACS (*)
Private Practice, Toth Plastic Surgery, San Francisco, CA, USA
Clinical Professor of Surgery, University of California,
San Francisco, CA, USA
e-mail: tothbryant@gmail.com
S.P. Daane, MD
Private Practice, San Francisco and San Ramon, CA, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_72
Of all the things you wear, your expression is the most important.
Janet Lane
The Botulinum toxin commonly used in practice under
the name BOTOX® is Botulinum neurotoxin A (BoNT A).
Its molecular structure is unique. The neurotoxin itself is a
150-kDa zinc-binding metalloprotease toxin that is endoge-
nously cleaved into a two chains; a 100-kDa heavy chain
joined by a disulfide bond to a 50-kDa light chain. When the
heavy chain attaches to the proteins on the surface of axon
terminals, it helps toxin get into neurons via endocytosis.
This light chain is a protease enzyme that attacks and proteo-
lytically degrades one of the intracellular fusion proteins
called SNAP-25, also known as syntaxin or synaptobrevin, at
the neuromuscular junction (NMJ).
SNAP-25 protein is a type of SNARE protein and is nec-
essary for vesicle fusion. Intracellular vesicles filled with
acetylcholine neurotransmitter are released from the axon
terminal. When the SNAP-25 protein is cleaved, the
Botulinum toxin prevents vesicles from attaching to the
membrane to release acetylcholine. Inhibition of acetylcho-
line release from the vesicles allows the toxin to interfere
with nerve impulses and causes temporarily flaccid paralysis
of striated muscle [5].
3 Botulinum Toxin Structure
Clinically injectable BOTOX® is a crystallized form of
BoNT A. It is a sterile, homogenous, lyophilized complex
with a molecular weight of about 900-kDa, which contains
the 150-kDa neurotoxin, other simple proteins that include
weak hemmaglutination proteins (HA), and nontoxic non-
HA proteins.
In small doses, BOTOX® blocks the release of acetyl-
choline from the presynaptic nerve terminal at the neuro-
muscular junction. This causes a chemical denervation of
the muscle, which usually peaks about 2 weeks after the
injection. Muscle function recovery after intramuscular
injection takes place normally within 12 weeks of injec-
tion as nerve terminals sprout and reconnect with the
endplate.
1073
1074 I.A. Nevdakh et al.

4 Botulinum Toxin Formulations
Botulinum toxin formulations are differentiated by their
molecular weight, protein size, serotype strain, and prepara-
tion/purification process. These factors determine their onset
of action, longevity of effect, and migration to the surround-
ing tissues from the injection side. Table 1 is a comparison of
the three formulations of BOTOX® that are clinically avail-
able, each from a different manufacturer.
Due to differences in the molecular size, uniformity of
neurotoxin complex, and potency, Botulinum toxin prepara-
tions are not interchangeable. For example, to have a similar
effect:
• 1 BOTOX® U = 3–5 Dysport® U
• 1 BOTOX® U = 50–100 U Myobloc Toxin B
BOTOX® is distributed as a vacuum-dried product in 100-
unit vials. In clinical use, the recommended safe dose ranges
from 5 to 400 U. No test dose is necessary. The therapeutic
index of BOTOX® is excellent, with an LD50 of 2,500–
3,000 U. No systemic spread or anaphylactic reactions have
been reported, however.
Allergan, BOTOX® manufacturer recommends the following:
• Store vials in a refrigerator between 2 and 8 °C. The prod-
uct should be administered within 24 h of being
reconstituted.
• Reconstitution is performed with 0.9% sterile, non-
preserved saline at a ratio of 100 units of BOTOX® to
2.5 mL saline (in clinical practice, many physicians dilute
the product with 4.0 cc [25 units per cc] to 5.0 cc [20 units
per cc] with excellent results).
5 Anatomical Considerations (Fig. 1)
In aesthetic surgery, the most common applications of
BOTOX® are glabellar frown lines, crow’s feet, horizontal
forehead lines, and lateral and medial brow lifts. More
advanced applications include nasal “scrunch and flare,”
upper lip “lipstick lines,” platysmal bands, facial asymmetry,
mental crease/chin dimpling. Multiple factors including
genetics, photoaging, smoking, underlying disease, gravity,
and muscular hypertrophy affect our appearance and facial
expressions as time goes by. Most facial expressions are a
product of facial muscles working together in concert.
BOTOX® works best when a facial expression is created by a
single muscle. Therefore, the best applications of BOTOX®
are in muscles that for the most part work alone, e.g., the
procerus, the corrugator, the frontalis, and others.
6 Commonly Targeted Muscular Areas
of the Upper Face
The Vertical Midline Glabellar Groove
• Corrugator supercilii
• Procerus
• Medial fibers of the orbicularis oculi
The Horizontal Forehead Lines
• Frontalis muscle
The Crow’s Feet
• Lateral fibers of the orbicularis oculi muscle
• Neck bands: platysma
• Lipstick lines: upper orbicularis oris
The corrugator muscle originates at the inner orbit of the
eye near the root of the nose and inserts into the skin of the
forehead above the center of each eyebrow. It pulls the eye-
brows and skin above the center of each eyebrow medially
and downward, forming vertical wrinkles in the glabellar
area and horizontal wrinkles at the bridge of the nose.
Corrugator most often acts simultaneously with two nearby
smaller muscles which are depressor supercilii (depress the
eyebrow) and procerus (pulls skin between the eyebrows
downward, which assists in flaring the nostrils and contrib-
utes to an expression of anger).

Table 1 Botulinum toxin formulations

BOTOX® (1989) Myobloc (2000) Dysport (1991)
Serotype/strain BoNTA/Hall BoNTBN/Bean BoNTA
Complex weight (kDa) 900 700 500–900
Excipients Sodium chloride Sodium chloride Lactose
Albumin Albumin Albumin
Sodium succinate
Final formulation Vacuum dried Solution Freeze dried
pH: ~7 pH: 5.6 pH: ~7
Units/vial 100 U 2,500/5,000/10,000 U 500 U
Total protein (ng) ~5 25/50/100 12.5
Botulinum Toxin: BOTOX®
Frontalis m.
Procerus m.
Corrugator supercilli m.
Nasalis m.
Levator labii superioris m.
Zygomaticus major m.
Orbicularis oris m.
Depressor labii inferioris m.
Platysma m.
Fig. 1 Normal facial muscular anatomy
The frontalis muscle, responsible for brow elevation,
is a bipennate muscle originating from the galea aponeu-
rotica near the coronal suture and inserts on the supercili-
ary ridge of the frontal bone and skin of the brow,
interdigitating with fibers of the brow depressors (the
procerus, corrugator supercilii, and orbicularis oculi
muscles).
Function of the primary smile muscle, the zygomaticus
major, results in the elevation of lateral upper lip diago-
nally with actions of laughing, smiling, and chewing.
Zygomaticus minor functions as a lip elevator and with the
zygomaticus major contributes to the nasolabial fold.
Forceful contraction of the zygomaticus muscles in anima-
tion produces synergistic effects in the periorbital region,
accentuated by contraction of the orbital orbicularis and
enhancing the radially oriented folds at the lateral canthus
(“crow’s feet”).
The orbicularis oris is responsible for forceful lip closure
and serves as a sphincter to the mouth. Contraction of this
muscle induces folds that radiate from the vermilion border.
This muscle is in part an antagonist to the lip elevators.
Figure 2 shows the actual injection patterns a clinician would
use to treat these areas.
1075
Temporalis m.
Orbicularis oculi m. (orbital portion)
Orbicularis oculi m. (palpebral portion)
Levator labii superioris alaeque nasi m.
Zygomaticus minor m.
Risorius m.
Depressor anguli oris m.
Mentalis m.
7 General Considerations Prior
to Treatment
Prior to injections, priority should be given to proper under-
standing of patient needs and expectations. The patients
should be informed about the possible minimal side effects
such as bruising, discomfort, and overtreatment. Other
important factors to consider are the patient’s occupation and
physiological and aesthetic differences between men and
women.
BOTOX® is considered a Category C medication; there-
fore, injections should be postponed until after pregnancy
and breastfeeding have ended. Relative contraindications are
patients with of neuromuscular transmission disorders (e.g.,
Lambert Eaton syndrome and myasthenia gravis), infection
at site of injection, glaucoma, and medications use including
aminoglycosides, penicillamine, quinine, and calcium chan-
nel blockers that are known to decrease neuromuscular
transmission.
If the patient’s current medical history includes use of
blood thinner medications such as aspirin, NSAIDs, herbs
or fish oil, advise the patient to stop it 1 week prior to the
treatment if there is no contraindication. In order to decrease
1076
Fig. 2 Overview of common injection patterns
pain levels in sensitive patients as well as to reduce the risk
of bruising and swelling, patients may use an ice pack or
tetracaine cream on the treatment area. Alcohol may be
applied to the injection sites for sterility but should be fully
dried before injecting the toxin due to toxin inactivation
from alcohol.
Post procedure, patients are given ice packs and asked not
to engage in vigorous physical activity for 24 h to prevent
BOTOX® from “washing away.” The patient should have a
return visit within 2 weeks if a touch up is necessary. To
record and assess the patient’s results, photographs can be
taken.
8 Common Complications Following
Treatment
Beyond the minimal complications mentioned above, eyelid
ptosis secondary to forehead treatment is the most common.
It is the result of the effect of BOTOX® on the levator pale-
brae superioris muscle after injection into the corrugator and
I.A. Nevdakh et al.
Corrugator m.
Orbicularis oculi m.
Orbital septum
Levator aponeurosis
Muller's muscle
Fornix
Palpebral
conjunctiva
Tarsus
Fig. 3 Elevators of the upper eyelid
procerus muscles and inactivation of forehead elevation (the
frontalis muscle).
Eyelid ptosis responds well to alpha-adrenergic agonist
eye drops phenylephrine (Neo-synephrine 2.5%, Sanofi
Winthrop Pharmaceuticals, New York); or apraclonidine
(Iopidine 0.5%, Alcon Labs, Texas). Remember that Neo-
synephrine is contraindicated in patients with narrow angle
glaucoma. These mydriatic agents work via stimulating
Muller’s muscle and elevate the upper eyelid, restoring it to
its normal position (Fig. 3).
9 Choice of Targeted Areas
With the patient in the upright position, she is asked to point
out which areas on the face are of concern holding a hand
mirror. While talking with the patient, we can easily notice
various patterns of facial animation and other features such
as brow asymmetry. The patient may then recline and injec-
tion begins with the crow’s feet. Small subcutaneous wheals
of 0.05 cc are injected superficially (to avoid bruising) within
the thin eyelid skin at intervals of 1 cm.
Attention is then turned to corrugator function on the
brow; here it is helpful to palpate the muscle while the patient
is contracting. Often the most powerful portion of the muscle
is inferomedial to the medial brow on the nasal radix at the
confluence of corrugator, orbicularis oculi, and procerus.
Injections here are deeper and spaced at 1 cm intervals as
well. Both the lateral canthal injections and inferomedial
brow injections can be expected to “open up” the aperture of
the eye.
Due to the supraorbital and supratrochlear nerves that run
just beneath the brow, these injections can be quite painful
and although topical anesthetics are usually ineffective here,
pretreatment with ice packs may be helpful to decrease dis-
comfort. The brow may then be injected in a “U” or “V”
shaped pattern with care taken to avoid injecting the infero-
lateral brow, which may risk ptosis. In certain cases, hyper-
Botulinum Toxin: BOTOX®
dynamic transverse lines over the lateral brow may be
unmasked and may require a touch-up procedure.
By selectively interfering with the underlying muscles’
ability to contract, existing frown lines are smoothed out and
in most cases are much less noticeable within a week.
10 Specific Considerations: Glabellar
Frown Lines
Glabellar frown lines result from the overaction of procerus
and corrugator supercilli. These lines are most commonly
seen in patients with excessive sun exposure, nearsighted-
ness, and habitual frowning. While injecting in the supraor-
bit, it is important to acknowledge the patient’s brow shape.
The classic female brow shape is high and arching, 1 cm
above the supraorbit, with the highest portion above the lat-
eral canthus. The medial and lateral portions of the brow
align horizontally. The horizontal male brow is characterized
by greater muscle mass and may require more toxins versus
a female brow (Figs. 4 and 5). The medial fibers of the mus-
cle usually are more bulky than the lateral fibers, thus requir-
ing more toxins for paralysis. Occasionally, after the
injection, a side effect such as brow asymmetry can be
expected [6].
11 Specific Considerations: Crow’s Feet
and Natural Eyebrow Lifting
Lateral canthal/orbital rhytidosis, also known as crow’s feet,
is the name given to the wrinkles at the outer corner and bot-
tom portion of the eyes due to hyperkinetic contraction of
orbicularis oculi and hypertrophy of it fibers over the time,
Fig. 4 Corrugator before BOTOX® injection
1077
producing wrinkles that extend radially from the lateral can-
thus (inferolaterally oriented crow’s feet are caused by the
action of zygomaticus elevating the malar fat pad and should
not be treated with BOTOX®).
Using BOTOX® injections at the lateral canthus will
cause chemical denervation and soften the muscle. It has
proven useful both as a primary treatment for certain facial
rhytids and as adjunctive agent for a variety of facial aes-
thetic procedures to obtain optimal results. Prior to the injec-
tion, patient is asked to smile broadly; while patient is
smiling, physician should notice the center of the crow’s feet
and assess the degree of orbicularis hypertrophy. In a good
candidate, a thick muscle band can be seen in lateral orbital
region (Figs. 6 and 7).
Eight to twelve units of BOTOX® may be used to inject
into each side of the raised folds of the skin following the
topographic location of the muscle. In order to prevent bruis-
ing, small subcutaneous wheals of 0.05 cc are injected super-
ficially at the side that is approximately 1.0–1.5 cm from the
lateral orbital rim and 1 cm above the zygoma. Theoretically,
if severe lower lid weakness occurs, the patient can be at risk
for keratitis.
12 Pharmacologic Temporal Brow Lift
As we age, the forces of gravity and loss of elasticity in the
forehead along with excessive orbicularis oculi muscle pull
makes the lateral brow component become more ptotic rela-
tive to the medial brow. “Chemical brow lift” is the term for
naturally lifting the eyebrow by relaxing a specific group of
forehead muscles. These muscles include the corrugator
supercilii, procerus, and the superolateral fibers of orbicu-
laris oculi, which as a group are the brow depressors. If one
Fig. 5 Corrugator after BOTOX® injection
1078
Fig. 6 Orbicularis before BOTOX® treatment
Fig. 8 Frontalis before BOTOX® treatment
truly wants to lift the brow, one should avoid placing
BOTOX® into the lateral frontalis muscle as this will result in
lowering of the eyebrow.
By injecting BOTOX® into the superolateral portion of
orbicularis oculi below the lateral third of the brow, we dimin-
ish the hyperactive muscle function that relaxes this area. This
way patients can expect an aesthetically pleasing high arching
of the lateral brow, which “opens” the upper part of the face
and presents a more refreshed appearance. Injecting BOTOX®
in this manner should allow the eyebrow to raise by 1–2 mm.
13 Frontalis Transverse Forehead Lines
The main antagonist of all the brow depressors, the frontalis
muscle, elevates the eyebrows and the skin of the forehead.
The fibers of the frontalis are oriented vertically, causing
I.A. Nevdakh et al.
Fig. 7 Orbicularis after BOTOX® treatment
Fig. 9 Frontalis after BOTOX® treatment
forehead wrinkles to be oriented horizontally. An important
factor to keep in mind regarding forehead wrinkles is to dif-
ferentiate individuals who overuse the frontalis for expres-
sion from those who are compensating for preexisting brow
ptosis. As mentioned above, one should avoid total paralysis
of frontalis, since this will likely worsen brow ptosis and lead
to loss of expression as described above (Figs. 8 and 9).
14 Other Applications of BOTOX®
14.1 Facial Nerve Injury
Children with facial nerve injuries or cervical dystonia and
adults with facial hemiparesis due to Bell’s palsy, facelifting
injury, or synkinesis can expect dramatic improvement with
BOTOX® by injecting the overpowering muscles on the
Botulinum Toxin: BOTOX®
Fig. 10 Use of BOTOX® in facial paralysis (pre)
Fig. 11 Use of BOTOX® in facial paralysis (post)
unaffected side (Figs. 10 and 11). The central mentalis mus-
cle is responsible for contracting the chin and helping to
raise it. Laterally located depressor labii inferioris pulls
down on the corner of the mouth and the platysma inserts to
the lateral chin and oral commissure. Depressor anguli oris
pulls down the corner of the mouth as well. These muscles
are injected with BOTOX® on the unaffected side to create a
symmetrical smile in cases of paralysis such as marginal
mandibular nerve injury after facelifting (Fig. 12).
14.2 Perioral Rejuvenation
Most patients dislike signs of aging around the mouth. As we
age, the upper lip lengthens and sags and vertical wrinkles
1079
Fig. 12 Congenital paralysis of the depressor of the lip
appear, first on the upper lip, then on the lower lip. The naso-
labial fold furrows with ptosis of the malar fat pads, and the
corners of the mouth droop into deep marionette lines, which
give an unhappy appearance. Patients desiring lipstick line
treatment are asked to “pucker” and 3 U superficial injec-
tions are made within furrows well above the vermilion bor-
der at 1 cm intervals. Patients should understand that they
may not be able to drink through a straw or whistle but they
will not drool or look strange after upper lip injections. In
patients with gummy smile or a long face, BOTOX® can be
used, to lengthen the upper lip and diminish nasolabial folds
by injecting perinasally into the levator labii superioris
muscle.
BOTOX® can be also injected to the masseter muscle for
nonsurgical facial contouring or treating benign masseteric
hypertrophy, and can be used in the masseter in conjunction
with injections in the occipital area to treat migraines. The
effect can take months to appreciate and can last more than a
year in most patients using a high-dose approach; in patients
using the low-dose approach, every 3 months the treatment is
required. Injection of BOTOX® to the masseter muscle can
also benefit patients with bruxism resulting in severe
headaches.
14.3 Platysmal Bands
The platysma muscle originates inferiorly from the pectora-
lis and deltoid fascia. It crosses the sternocleidomastoid at
the midlateral neck. The lateral bands of the platysma mus-
cle facilitate facial expression by lowering the corners of the
lower lip. Its posterior fibers continue superiorly to join the
superficial musculoaponeurotic system (SMAS) of the face.
1080 I.A. Nevdakh et al.

Age-related downward pull of the platysma muscle creates

vertical fibrous bands. Skin laxity over the platysma muscle
can produce horizontal rhytids. Vertically oriented platysmal
bands may be injected in patients with a hypertrophied or
sagging muscle. For treatment of the platysmal bands,
patients are asked to strain their neck, and dominant bands
are injected at intervals of several centimeters (Fig. 13).
Most patients require a total of 14–20 units injected very
superficially. Very rarely, injection into platysma muscles
can result in dysphagia from diffusion of toxin into the mus-
cles of deglutition. If the sternocleidomastoid muscle is
injected additionally either by mistake or due to a diffusion
effect, some patients can experience neck weakness, which
is especially noticeable when a patient attempts to raise the
head from a supine position. Avoidance of adverse effects is
achieved by using the lowest effective dose and precisely
placing toxin into the platysma.

15 Immunologic Considerations

Very occasionally, some patients may develop an immune

response to BOTOX®, which may reduce the effectiveness of
treatment. This immune response happens due to the protein
complex in BOTOX®; in some patients, the body’s immune
system may respond by producing neutralizing antibodies
capable of inactivating the protein’s biological activity. Two
types of BOTOX® neurotoxin have been marketed: the origi-
nal batch of neurotoxin prepared by Shantz in November
1979 (“Batch 79–11”) and the newer neurotoxin produced in
1997 (“Batch BCB 2024”), which replaced batch 79–11 and
in current use. The newer neurotoxin has a decreased protein
load compared to the original BOTOX® and therefore appears
to have a lower potential to induce antibody, a fact corrobo-
rated by research studies.
Antibody formation is more of a concern when patients
must receive frequent injections or when it is used to treat
medical conditions such as cervical dystonia that require
higher doses. However, recent long-term studies have indi-
cated that immunogenicity is a relatively minor concern. The
BOTOX® package insert advises “The potential for antibody
formation may be minimized by injecting with the lowest
effective dose given at the longest feasible internals between
injections.”
Fig. 13 Use of BOTOX® for platysmal bands
a look of surprise or astonishment. All possible side
effects should be explained in detail to the patient prior to
the procedure. BOTOX® works within 1–3 days of treat-
ment and typically wears off linearly over 3 to 4 months.
With subsequent injections, facial muscles do not recover
their full preinjection strength. BOTOX® has a wide array
of reconstructive surgical indications, and BOTOX®
injections can be performed alone or in conjunction with
more invasive rejuvenation procedures [7–11].
Despite its myriad cosmetic uses, the ultimate benefit
of BOTOX® is that patients undergoing facial injections
have measurable mood elevation [12–14].
References

Conclusions 1. Package Insert: Botox (Botulinum Toxin Type A), Purified

The face shows signs of attractiveness, aging, and indi-
vidual identity. Different anatomic components of the
face contribute to different expressions and cosmetic
deformities. An understanding of facial anatomy, muscu-
lar functions, and an individual patient’s needs when
treating with BOTOX® is paramount. A desired end result
is a patient with a refreshed, youthful appearance, without
Neurotoxin Complex. Allergan Inc., Irvine 92715, revised 08/2015
2. Scott AB (2004) Development of botulinum toxin therapy.
Dermatol Clin 22(2):131–133
3. Erbguth FJ, Naumann M (1999) Historical aspects of botulinum
toxin: Justinus Kerner (1786–1862) and the “sausage poison.”.
Neurology 53(8):1850–1853
4. Hathaway CL (1993) Clostrdium botulinum toxin formation in
Clostridium botulinum: ecology and conrol in foods. Hauschild
AHW (ed). Marcel Dekker, Inc. New York. pp 3–20
Botulinum Toxin: BOTOX®
5. Matarasso SL (2008) Botulinum toxin: concepts and use in 2008.
Adv Dermatol 24:1–13
6. Ramirez OM (1995) Spastic frontalis: eyelid laxity syndrome.
Presented at the Annual Meeting of the ASAPS, San Francisco,
19–24 March 1995
7. Borodic GE, Ferrante RJ, Pearce LB et al (1994) The pharmacol-
ogy and histology of the therapeutic application of botulinum toxin.
In: Jankovic J, Hallett M (eds) Therapy with botulinum toxin.
Marcel-Dekker, New York, pp 119–157
8. Carruthers J, Fagien S, Matarasso SL (2004) Botox consensus
group: consensus recommendations on the use of botulinum toxin
type a in facial aesthetics. Plast Reconstr Surg 114(6 Suppl):1;
Dressler D, Hallett M (2006) Immunological aspects of Botox,
Dysport and Myobloc/NeuroBloc. Eur J Neurol 13(Suppl 1):
11–15
1081
9. Jankovic J, Vuong KD, Ahsan J (2003) Comparison of efficacy and
immunogenicity of original vs. current botulinum toxin in cervical
dystonia. Neurology 60(7):1186–1188
10. Jancovic J (1994) Botulinum toxin in movement disorder. Curr
Opin Neurol 7:358–366; Clark RP, Berris CE (2005) Botulinum
toxin: a treatment for facial asymmetry caused by facial nerve
paralysis. Plast Reconstr Surg 115(2):573–374
11. Fagien S (1998) Extended use of botulinum toxin a in facial aes-
thetic surgery. Aesthet Surg J 18(3):215–219
12. Finzi E, Wasserman E (2006) Treatment of depression with botuli-
num toxin A: a case series. Dermatol Surg 32(5):645
13. Lewis MB, Bowler PJ (2009) Botulinum toxin cosmetic therapy
correlates with a more positive mood. J Cosmet Dermatol 8(1):24
14. Beer K (2010) Cost effectiveness of botulinum toxins for the treatment
of depression: preliminary observations. J Drugs Dermatol 9(1):27
 Filler
M. Greco, T. Vitagliano, and A. Greto Ciriaco
Taking care of the body has always been a common practice.
Self confidence comes with the balance of the exterior and
interior body to bring about a sense of well being.
Beauty has therefore always been a goal to reach, just like
the one to fight diseases or overcome suffering; a goal that
sinks its roots in traditions and over the centuries has taken
on its own identity and its own image inspired by the aesthet-
ics of different eras.
We can talk about aesthetics, however, only since the clas-
sic era, although in all ages people have always tried to appear
good looking. Already in ancient Egypt, about 3,500 years
before Christ, oils and minerals from the East which were used
as ointments for the treatment of the body were imported.
India, in fact, was rich of raw materials suitable for cosmetics
and perfumery, in such a way that its civilization exalted these
arts in both religious practices and in common life ones.
The real revolution of the concept of beauty started from
ancient Greece at around the fifth century BC. It was
entrusted to sculptors of the time that precisely concretized
aesthetic theory they developed in their works.
Beauty products and cosmetics practices came in Europe
mainly through the refined civilization of ancient Greece. The
Romans then learned to treat their physical appearance only
after the conquest of Greece by importing the refined habits.
The influence was so strong that manuals of beauty as De
Medicamina Faciei Femineae of Ovid were even published.
M. Greco, MD (*)
Dipartimento di Medicina Sperimentale e Clinica,
Università “Magna Graecia” di Catanzaro, Catanzaro, Italy
e-mail: manfredigreco@unicz.it
T. Vitagliano, MD
U.O.C. di Chirurgia Plastica Ricostruttiva ed Estetica,
Fondazione Oncologica “T. Campanella”, Polo Oncologico di
Eccellenza “Germaneto”, Catanzaro, Italy
A.G. Ciriaco, MD
U.O.C. di Chirurgia Plastica, Ricostruttiva ed Estetica,
Università “Magna Graecia” di Catanzaro, Catanzaro, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_73
With the fall of the Roman Empire, models of classic
beauty and body care fell too. We must get to feudal times to
find appreciation for beauty and care of oneself again. The
Renaissance brought the need to find remedies considered
necessary to make one aesthetically “perfect” instead of
being content with what nature had bestowed.
Leonardo da Vinci is one of the artists and Renaissance
scholars that contribute most to the achievement of aesthetic
with the formulation of his theory of the proportions between
various parts of the body. He believed that harmony between
the different anatomical units of the face was necessary to
achieve the concept of true beauty. This new interest for
beauty led to the publication in 1562 of the first treatise of
cosmetology entitled The Ornaments of Women by
Mariniello in which the art of celebrating the beauty of the
body predominates.
The radical changes made with the advent of the French
Revolution lead to the new patterns of life and new aesthetic.
The glories and excesses cultivated in the courts were substi-
tuted by ideas of romance where physical appearance became
the mirror of the soul, and body care in a few decades could
begin with the use of the first products supplied from the first
cosmetic industries.
After World War II the film industry, particularly in the
USA, brought a new aesthetic following the deprivation of
the two world wars. The development of other media, televi-
sion, and magazines in particular encouraged the increasing
trend to consider as aesthetic those proposed by showbiz and
walkways. A better economical position and the new discov-
eries of science, cosmetology, surgical techniques, and medi-
cine allowed men and women of our days to adapt themselves
more and more to the models proposed and selected for per-
fection that one identified in the correction of signs of aging
and therefore all the little imperfections present especially
on one’s face.
The elimination of wrinkles and the correction of hypo-
plasias of the face became therefore preconditions of the aes-
thetic canon of the last decades.
1083
1084
The new concept of beauty also led to the birth of aes-
thetic medicine, assisted by the support of pharmaceutical
research in this new sector that provided a wide range of
injectable materials that allowed the filling of wrinkles,
folds, troughs, and deep nasolabial grooves or gave propor-
tions to cheekbones, chin, or lips. However, despite the
increasing number of specialist dealing with medicine and
surgery aesthetics, even today the national and international
literatures are low in information about the filling material
used in clinical practice.
Whatever the reasons that led to the correction of one’s
blemishes, whether seen as the need to correct changes or
simply as the only resource available against the ancestral
fear of senescence, what is certain is the consideration of
body image as the most immediate and convincing testimony
of an equilibrium of physical and mental consciousness.
1 Introduction
The search for the ideal material for filling defects of the
body has elicited the interest of physicians and men of sci-
ence for over a century. The characteristics of an ideal filler
should be summarized as follows: biocompatibility and
security, stability in the implant site, and the maintenance of
volume and malleability. Besides, an ideal filler must not
cause cutaneous or mucosal protrusions, should induce the
slightest foreign body reaction, must not be removed by
phagocytosis, must not be able to migrate to distant loca-
tions, and must not cause granuloma from foreign body [8].
The first attempt of filling a soft tissue dates back to the late
1800s when Neuber removed an adipose tissue from a
patient’s arm and infiltrated it into a face in order to correct a
depression of the skin.
A few years later, another attempt to fill, this time for
purely aesthetic purposes, was practiced by Gerunsy that
used some paraffin as injectable prosthesis material to recon-
struct a testicle. The filler effect of paraffin produced excel-
lent aesthetic results and therefore its use grew for the
treatment of facial deformity. However, the fact that it pro-
duced adverse reactions over time was soon discovered lead-
ing to the formation of paraffinoma or granulomas in the
location of the injection, and its use was soon inadvisable.
In the late 1940s another product consisting of silicone oil
with high viscosity was tested and introduced on the market,
first in Europe and 20 years later in the USA.
The silicone in liquid form was the first substance to be
used on a large scale in clinical practice as filling material.
The interest in this substance dates back to the late 1940s
after a toxicological study in 1948 that called it a physicolo-
cally inert substance. The first clinical applications started
first in Europe and Asia in the late 1940s and the beginning
of the 1950s and then arrived in the USA just around the
M. Greco et al.
beginning of the 1960s where it was widely used even if the
US Food and Drug Administration had never authorized its
use. Only in 1976 that the chemical composition and tech-
nique of injectable filler made from collagen in California
was used. From these first clinical trials in Palo Alto at the
end of the 1970s, more and more molecules were studied and
put on the international market as filler. In 1981, the US Food
and Drug Administration approved the use of bovine colla-
gen to fill cutaneous depressions. However, the high risk of
allergic reactions, in combination with the short-lived prod-
uct action, led to the need to find new filling materials such
as autologous collagen, hyaluronic acid, or materials of syn-
thetic origins [3, 7, 10]. Topics on adipose cell transplanta-
tion and injection of platelet-rich plasma (PRP) are
intentionally not treated here since we preferred to examine
only those injectable substances marketed as ready-to-use
products, therefore do not require preparation comparable to
those used in “surgery” as in fat transfer or in “laboratory” as
in the case when we use platelet gel.
2 Classification of Filler
Filler (noun derived from the verb to fill) means a substance
derived from biological or synthetic-looking gel, liquid, or
solid that is injected through the skin or subdermis (deep
filler) in order to fill, emphasize, or support a limited area of
the skin or part of the body (mainly at the level of the face)
for cosmetic purposes only [1].
Fillers can be classified into two groups: the ones of bio-
logical origin and the ones of synthetic origin (Table 1) [14].
For each of them, a subclassification can be made depending
on the implant site, superficially and deeply. The organic fill-
ers are made of molecules of natural origin and for this rea-
son undergo skin resorption more or less rapidly; usually
their duration varies from 4 months to a year. How long they
stay in the dermis is affected by extrinsic factors, including
alcohol intake, cigarette smoking, and exposure to UV rays
as well as intrinsic factors related to the concentration of the
active substance and its biological activity. To increase its
durability within the site of injection, some products are
made chemically more resistant to the natural process of
degradation by a cross-linkage of molecules that change
Table 1 Classification of filler
Temporary biological filler Permanent synthetic fillers
Collagen Polymethylmethacrylate microspheres
Hyaluronic acid Polyacrylamide cross-linked polymers
Agarose injectable gel Silicone
Polyvinyl alcohol Hydroxyapatite
Dextran
Filler
their viscoelastic properties and therefore the time of degra-
dation. The greater the degree of cross-linkage, the more the
molecular weight and viscosity increase, so the time of
resorption is longer [9].
The organic fillers are substances of animal origin of bac-
terial synthesis and make up the class of fillers most com-
monly used in clinical practice. The synthetic fillers that
have this name because of their nonnatural origin can be
divided into partially synthetic or totally synthetic and have
very slow resorption characteristics, which allows them to
stay in the dermis for a period ranging from a few years to
permanence, depending on the type of molecule used. They
are made of synthetic polymers and their common character-
istic is that they need the simultaneous presence of an organic
carrier agent, generally made of alcohol, collagen, or water,
which besides stabilizing the product in the form of gel leads
to degradation.
So the permanence is limited to the synthetic component
that is inherited by the tissue site of injection. This feature
makes their system more technically demanding, requiring
skilled personnel and precision injection, and needs retouch-
ing at a distance of 1 or 2 years to have an optimal result.
Their removal from a body is possible although technically
difficult. The subclassification in superficial and deep is
based on the site of the injection. The superficial fillers, often
of natural origin, are placed in the superficial dermis and are
used in the filling of more superficial wrinkles. The deep fill-
ers, on the contrary, have very often synthetic origin and
higher molecular weight, and their clinical use is for the cor-
rection of all deep skin depressions since these are injected
into the deep dermis or subcutaneous tissue [2].
2.1 Temporary Biological Fillers
2.1.1 Collagen
It is well known that collagen is the protein that is in the skin
and that represents about 80 % of the dermal matrix.
Currently 28 different types of collagen are known in the
literature, although most are particularly abundant in the skin
tissue, bone, tendon, and cornea. The type II are those which
made up the matrix of the cartilage tissue of the interverte-
bral disc and vitreous eye, and the type III are those present
in adults at the skin level and in the tissue scar granulation.
Introduced into the market at the end of the 1970s, colla-
gen is the most studied filler and has the largest case study
and most clinical and scientific documentation. At the
moment there are three types of collagen used in clinical
practice: bovine origin collagen, swine origin collagen, and
human origin. The first is extracted from the dermis of cattle
carefully selected from strictly controlled farms. The second,
that is, of swine origin, is extracted from the tendon tissue of
the pig. It has just been placed on the market and is known to
1085
have a good integration with the dermal tissue of the recipi-
ent because of the structural similarity between pig and
human collagen. This allows a longer permanence of the
product at the injection site, thus ensuring a longer aesthetic
result with less chance of allergic reaction. The human col-
lagen, finally, is extracted and purified from humans and for
this reason doesn’t have either short- or long-term side
effects. There are different formulations, depending on the
different clinical use. The intradermal test is done twice to
assess for possible allergic reactions to the proteins for all
products made from bovine collagen (biological or
semisynthetic).
Patients must observe a 4-week period clinical observa-
tion before a filling session can be made. The double test is
performed by injecting a small amount (0.1 ml) of the filler
in the subcutaneous, generally on the forearm, marking the
site of inoculation with an indelible pen. If itchy wheal, red-
ness, or swelling of the area appears during the observation
time, the administration of the product must be avoided on
the sensitive person. If instead the response to the first test is
negative, a second evaluation after 3 days is performed, that
is, another small amount of product is subcutaneously
administrated in the contralateral forearm. If the answer to
the second test is once again negative, before implanting the
tested filler, it is necessary to wait another week where the
appearance of late sensitization will be observed. If, how-
ever, redness and edema that persist for more than 6 h appear
or should the person notice an itching sensation or hardening
in the region of the inoculation, the test can be considered
positive. The administration of the product is normally done
in an outpatient setting and does not require the use of anes-
thetic drugs. It can be inoculated in one or more sessions
depending on the need of a possible retouching because of
the time of resorption which is quite short for the bovine one,
about 3 months; instead, the ones of human origin last longer
on average from 4 to 6 months and even longer for that of
porcine origin whose resorption takes from 9 to 12 months.
In the case of an allergic reaction to the infiltration of colla-
gen, this is resolved in a few months’ time with the total
reabsorption of the injected substance.
2.1.2 Hyaluronic Acid
Hyaluronic acid is a natural polysaccharide that is highly
water soluble which is similar to what makes up most of the
amorphous matrix of the dermis [11, 12]. The lack of antige-
nicity and immunogenicity allows this substance to be used
in clinical practice in various fields of medicine. Its main
characteristic is that it can join considerable number of water
molecules so it confers an extremely natural filler to the tis-
sues in which it is injected. Besides increasing skin hydra-
tion, it stimulates the synthesis of the connective tissue. It’s
been on the market since the mid-1990s, used clinically as a
filling material to mitigate wrinkles or define the contours of
1086
the face; there are two types in different derivation on the
market: avian (from cockscomb) and bacterial (Streptococcus
equinus). Its time of resorption is variable, influenced by
intrinsic and extrinsic factors of all organic fillers. On aver-
age the duration in the dermis varies from 3 to 4 months. To
increase the effect and duration, getting results therefore in
the long term, there are formulations on the market based on
hyaluronic acid with the combination of larger particles and
with more cross-linked connections that increase its molecu-
lar weight. It is produced in a clear and viscous gel form,
suitable for deep infiltration adding volume to the tissue site
of injection [13]. The greater density of some formulations of
hyaluronic acid allows clinical use in the remodeling of some
body parts, such as the enlargement of the buttocks or calves,
the correction of irregularities after liposuction, or remodel-
ing of male chests. A few years ago these formulations
started to be used for moderate volume increases of the
breast or in the correction of small breast asymmetries in
women who did not want to undergo surgical prosthetic
implantation, but this use was challenged and banned in
some countries (France). The increase that can be obtained
with hyaluronic acid is considerably low; it can ensure an
average increase of 100 cc intended, however, to a limited
duration estimated at around 12–18 months instead of breast
augmentation surgery. The sessions take place in the outpa-
tient’s department with or without the use of local anesthet-
ics. Unlike fillers with a basis of collagen, hyaluronic acid
does need allergic testing before its clinical use.
2.1.3 Injectable Agarose Gel
The agarose that belongs to the family of galactans, sugars
with five carbon atoms, is a polysaccharide that has the char-
acteristic of becoming hydrocolloid in the presence of water
in a gel form that is easily injectable. Its infiltration does not
require evidence of allergic sensitization as the agarose is
highly biocompatible and doesn’t stimulate immune
response. It’s suitable not only in the correction of skin blem-
ishes such as grooves, wrinkles, or scars, but it also increases
volumetric tissue or corrects traumatic injuries. It doesn’t
last long; it is generally reabsorbed by the body after a period
of 8 months. It is used in outpatient treatment with or without
the use of anesthetic drugs.
2.1.4 Polyvinyl Alcohol
Its chemical structure is that of a reticulated polymer with a
very high degree of purity. It does not require allergy testing
because there are no reports of immune sensitization reac-
tion. It is completely absorbed by the body and transformed
into water and carbon dioxide. The formulations on the mar-
ket present it in a clear gel form that, once inoculated subcu-
taneously for the correction of wrinkles, has a long duration
of action with a resorption after approximately 1 year after
M. Greco et al.
implantation. It is use is in outpatient treatment and is used
for the correction of imperfections of small- and medium-
sized grooves or skin wrinkles or to increase the volume of
small areas of depression. In most cases it does not need
drugs with local anesthetic.
2.1.5 Polylactic Acid
Polylactic acid is a product of biocompatible and biodegrad-
able chemical synthesis; it belongs to the family of alpha
hydroxy acids which does not stimulate the immune response
of an organism. Instead, it possesses the characteristic of stimu-
lating the synthesis of new collagen but is degraded in 8–10
months. The crystalline form of this acid, L-polylactic acid, is
usually used. It is mainly used to increase the volume of
depressed areas such as skin wrinkles, folds, scars, and signs of
skin aging and to correct the loss of volume like the decrease
of adipose tissue in the face that occurs in malar hypoplasia [4].
Its clinical use is suitable in the filling of the deep furrows of
the naso-buccal region, and wrinkles on the face, neck, and
hands. This product should be suitable into the deep layers of
the subcutaneous inoculation avoiding the upper layers where
this substance can cause the appearance of nodules or papules.
The kinetics of degradation is slow.
2.1.6 Dextran
It comes in a gel form. It’s made up of dextran (40 %) dis-
persed in solution with hyaluronic acid (60 %). The latter is
quickly absorbed by the body, while the dextran with long
duration can remain subcutaneously for about a year before
being completely reabsorbed. This drawback makes it neces-
sary to repeat the outpatient injection sessions before one
gets good lasting results. It does not require testing of
immune reaction. Suitable to increase the volume of lips,
cheekbones, and small areas of skin depression, it is also
suitable for the correction of medium-sized deep skin fur-
rows, wrinkles, and scars.
2.2 Permanent Synthetic Fillers
2.2.1 Silicone
Although used in the past, silicone oil is no longer used in its
original form because of it s significant side effects both in
the tissues at the injection site, such as the appearance of the
so-called siliconoma, and other surrounding tissues, due to
the migration of silicone molecules which are able to trigger
systemic autoimmune diseases [6].
Moreover, very often, the infiltration of this substance
produces cosmetic damage difficult to resolve as distorting
hyperfibrosis and hardening of the treated areas. Currently,
the clinical use of silicone as a filling material is limited to
substances whose formulation needs microspheres of
Filler
silicone rubber at 25–35 % suspended to 65–75 % in a bio-
compatible injectable gel (Figs. 1 and 2).
2.2.2 Polymethylacrylate in Microspheres
Regarded as a semipermanent implantation, polymethyl-
methacrylate is marketed in the form of microspheres in a
collagen matrix fluid. While the first remains within tissues
for long periods, collagen, on the contrary, is readily reab-
sorbed. The injection should be in-depth and requires a skin
sensitivity test 30 days before the procedure. Once infiltrated,
adjustments but not the removal of the substance can be made.
2.2.3 Polyacrylamide Reticulated Polymers
Polyacrylamide is generally marked under a gel form in a
2 % formulation in association with a carrier agent consist-
ing mostly of non-pyrogenic water.
Fig. 1 Outcomes of infiltration of silicon. Note the presence of a sili-
conoma at the level of the lower lip
Fig. 2 (a, b) Hyperfibrosis deforming after treatment with silicone oil at the level of the lips. Note the excessive projection of the lips of the face
and the complete disharmony
1087
The filler creates a capsule in the injection site which
makes it difficult to remove but still allows the possibility to
perform injections of retouching in the area to be treated.
The elective areas of implantation are the zone of the nose,
lip, and cheek bones. It is preferentially suitable for the treat-
ment of nose, cheeks, or chin area blemishes.
2.2.4 Hydroxyapatite
The use of fillers consisting of calcium hydroxyapatite, a
synthesis analogue of inorganic constituents of bone tissue,
began in the early 1980s and is still marked in the form
of spherules in hundreds of different products. It is mainly
used as a bone substitute, because it is a synthetic analogue
of inorganic constituent of teeth and bones, but also has the
ability to generate a matrix tissue identical to that of the tis-
sue surrounding the injection region. This allows a longer
duration effect of the filler since the new matrix is able to
compensate the slow absorption of calcium hydroxyapatite.
Because of its physical and biological characteristics, the
aesthetic clinical use is the correction of the ipovolumet-
rie of the bridge of the nose. The product is marketed as
a microspherule form suspended in an aqueous gel that,
once injected into the desired site, is not able to migrate
in the nearby areas as it generates a tissue response that
leads to the formation of microcapsules that surround the
microspherules.
3 Injection Technique
The infiltration session does not require the same surgical
preparation; they are outpatient since they are sessions that
do not need incisions and only in certain case need topical
or infiltrative anesthetic [5]. As with any procedure, you
must undergo a thorough physical examination before
1088
treatment to see the state of good general health or presence
of inflammatory pathologies at the site that may be treated
that may represent absolute contraindications to the system
of the filler. We must then assess this information and the
contraindications or the benefits of a given treatment and
recommend the most beneficial in relation to the defect to be
treated. The interview with the patient is important to under-
stand what he/she needs and expects. During the interview
doctors must also explain the degree of correction obtained
with that particular type of treatment, its duration, and its
general and specific complications. Once you have the con-
sent, it is advisable to take pretreatment photos that will
serve as a yardstick to evaluate the result after some time.
The injection site and technique of infiltration vary depend-
ing on the material used (Fig. 3), the type of remodeling
chosen, its duration, and the part to treat. While for some
Fig. 3 Based on the characteristics of the product and the desired
effect, the place of infiltration can be superficial, medium, or deep
Fig. 4 Fill pattern of a cutaneous depression after infiltration of a filler
M. Greco et al.
fillers the infiltration site part is made of superficial dermis
for other substances, it is instead formed by the deep dermis
or subcutaneous tissue and the same substance may undergo,
if injected in a different location, an immediate degradation,
thus reducing its clinical effect or producing side effects and
anti-aesthetics.
The depth of the implantation, then, depends strictly on
the material used and the defect to be treated.
A too superficial infiltration could easily lead to the for-
mation of granulomas, while too deep infiltration may reduce
the degree of filling and therefore compromise the result of
the session (Fig. 4).
The area to be treated must have optimal lighting and
must always be thoroughly disinfected. You should trace the
outline of the area with a dermographic pencil with the
patient in the upright position or sitting in order to assess the
best conditions possible, defects to be treated, and the effects
of gravity on the tissues.
Any residual makeup or other substances must be removed
before performing the infiltration of the filler.
There isn’t a fixed dose of product to be used. This is pro-
portional to the surface to be treated; one to three vials can be
used, but a good rule would be not to exceed 3–4 ml per ses-
sion dose.
Depending on the substance used, besides the most
effective technique, you should choose the most suit-
able materials. If for some substances such as collagen or
hyaluronic acid a 30-gauge needle can be used, for other
substances, such as calcium hydroxyapatite, a 27-gauge
needle can be used. More superficial imperfections do not
usually require a very deep injection, placing the needle in
a parallel way to the skin, placing the needle in the sub-
cutaneous tissue surface, and releasing the product as the
needle is withdrawn. This technique is particularly suit-
able for lips (Fig. 5a, b) where, beside the line of vermil-
Filler 1089

Fig. 5 Surface implant filler at filter level of the upper lip. The needle is inserted parallel to the line of the thread and the product is released as the
needle is withdrawn

ion, it is important to highlight the filler with some deeper

injections that give volume to the lip itself. Even in the
case of the treatment of the nasolabial crease, the place-
ment of the product is superficial and is in front of the
same furrow.
In contrast, in defects that are more pronounced and where
there is a need of volume, such as hypoplasia of the malar, the
site of the injection is deeper and the needle must penetrate
the skin with an acute angle that can vary from 25° to 45° and
almost reach the bone. When finally the defect is serious,
repeated sessions of deep planting are needed; the injection
must be performed preferentially in the subcutaneous tissue
by injecting the needle with an inclination of 90° reaching the
periosteum and injecting the filler to give the desired volume
evenly. The infiltration technique should be as atraumatic and Fig. 6 Infiltration “linear threading”
painless as possible; for this reason needles which can pene-
trate tissues should be used to slowly release the product. The
whole procedure should take place in the shortest time possi-
ble, so the patient has less trouble mainly because the result-
ing edema may easily deceive the doctor over- or
underestimating the quantity of product to continue to inject.
In case there is an excess of the product, the mistake can be
resolved by injecting hyaluronidase; if the product injected is
hyaluronic acid being the hydrolytic enzyme, a delicate mas-
sage should follow. In the case of annoyance or strong pain, it
is better to use topical or injectable anesthetics.
The substance can be carried out using two special par-
ticular techniques: the linear threading or the “serial punc-
tures” (Figs. 6 and 7). Each of them requires a good manual
dexterity and excellent precision in the depth of the implan-
tation. The first technique is to insert the product within the
depressed tissue and for its entire length. Once within the
tissue to be treated, a substance is released gradually and is
directed linearly. Fig. 7 Infiltration “serial puncture”
1090
The product can be infiltrated in layers, repeating the
second infiltration along the same line of the first, in this
way increasing the final filler effect. This technique causes
minor discomfort because of the small number of injec-
tions. It allows for a better calibration of the amount used
as well as its distribution in the tissue. The best part of this
technique is a better implantation control and a greater
accuracy of the injection, yet it needs more injection with
more discomfort compared to the first. Another technique,
although used less, is the “fan” injection, that is, entering
into the skin using a single site that becomes the heart from
which to inject the filler by creating a shape that looks like
a fan. This technique is particularly indicated when the
defect to treat is very large. On the other hand, it generally
creates discomfort for the patient. In certain parts, such as
the cheeks, “the grid” infiltration technique can be used.
This method of administration requires multiple injections.
a b
Fig. 8 (a) Before treatment with polylactic acid at the level of the lips. (b) After treatment
M. Greco et al.
It is created by inserting the needle parallel to the skin sur-
face at the level of the mid-dermal surface. The product is
gradually released by tracing parallel lines that intersect at
90 degrees with other lines of injection forming a grid.
Once the product is released, it’s better to gently massage
the treated area to distribute the filler evenly. After the
implantation, the site must be gently massaged for a few
minutes to improve the distribution of substance.
Posttreatment medication is not needed and the use of cold
compression if the patient feels a slight tenderness is rarely
needed.
The patient is advised to avoid direct exposure to sunlight,
strenuous exercise the use of alcohol and cigarette smoking
for 24–48 hours post injection. Make-up can be applied a few
hours following the injections. Finally, the patient should be
reassured of the possibility of edema, erythema, or hematoma
in the area treated (Figs. 8, 9, 10, 11, 12, 13, 14, 15, and 16).
Filler 1091

a b

Fig. 9 Hyplopasia and asymmetry of the lips. (a) Before treatment with polyalkylamide. (b) After treatment

a b

Fig. 10 Combined treatment for the correction of nasolabial crease furrow and thin vermilion. (a) Before treatment with hyaluronic acid. (b) After
treatment

a b

Fig. 11 Combined treatment for the correction of nasolabial crease furrow and thin vermilion. (a) Before treatment. (b) After treatment
1092 M. Greco et al.

a b

Fig. 12 Asymmetry of the upper lip with thin vermilion. (a) Before treatment. (b) After treatment. The volume increase of the upper lip produces
a shortening of philtrum and the upper incisors are covered by the lip itself

a b

Fig. 13 Combined treatment for the correction of nasolabial crease furrow and thin vermilion. (a) Before treatment. (b) After treatment

a b

Fig. 14 Pronounced nasolabial crease. (a) Before treatment. (b) After treatment
Filler
a b
Fig. 15 Pronounced nasolabial crease. (a) Before treatment. (b) After treatment
Fig. 16 The areas of the face
prone to correctable blemishes
though the infiltration of
injectable substances
References
1. Bergeret-Galley C, Latouche X, Illouz YG (2001) The value of a
new filler material in corrective and cosmetic surgery: DermaLive
and DermaDeep. Aesthetic Plast Surg 25(4):249–55
2. Broder KW, Cohen SR (2006) An overview of permanent
and semipermanent fillers. Plast Reconstr Surg 118(3 Suppl):
7S–14
3. Christensen L, Breiting V, Janssen M, Vuust J, Hogdall E (2005)
Adverse reactions to injectable soft tissue permanent fillers.
Aesthetic Plast Surg 29(1):34–48
4. Danny V (2006) Soft-tissue augmentation and the role of poly-L-
lactic acid. Plast Reconstr Surg 118(3S):46S–54
5. De Maio M (2004) The minimal approach: an innovation in facial
cosmetic procedures. Aesthetic Plast Surg 28(5):295–300
6. Frish EE (1983) Technology of silicones in biomedical applica-
tions. In: Rubin L (ed) Biomaterials in reconstructive surgery.
Mosby, St Louis, pp 73–90
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7. Gladstone HB, Cohen JL (2007) Adverse effects when injecting
facial fillers. Semin Cutan Med Surg 26(1):34–9
8. Gottfried L, Vera M (2003) Ulrich charrier, human histology and
persistence of various injectable filler substances for soft tissue
augmentation. Aesthetic Plast Surg 27(5):354–66; discussion 367
9. Hutmacher DW, Goh JC, Teoh SH (2001) An introduction to biode-
gradable materials for tissue engineering applications. Ann Acad
Med Singapore 30(2):183–91
10. Lowe NJ, Maxwell CA, Patnaik R (2005) Adverse reactions to der-
mal fillers: review. Dermatol Surg 31(11 Pt 2):1616–25
11. Lupo MP (2006) Hyaluronic acid fillers in facial rejuvenation.
Semin Cutan Med Surg 25(3):122–6
12. Rohrich RJ, Ghavami A, Crosby MA (2007) The role of hyaluronic
acid fillers (Restylane) in facial cosmetic surgery: review and tech-
nical considerations. Plast Reconstr Surg 120(6 Suppl):41S–54
13. Smith KC (2007) Practical use of Juvéderm: early experience. Plast
Reconstr Surg 120(6 Suppl):67S–73
14. Smith KC (2008) Reversibile vs. nonreversible fillers in facial aes-
thetics: concerns and considerations. Dermatol Online J 14(8):3
 Chemical Peel
A. Tedeschi, D. Massimino, G. Fabbrocini, and G. Micali
1 Introduction
Chemical peeling is a dermatological procedure indicated
both for unaesthetic cutaneous conditions and for skin reju-
venation. It consists of the application of one or more chemi-
cal exfoliating compounds to the skin in order to destruct
first and then regenerate part of epidermis and dermis to
improve physical appearance [1, 2].
Many chemical substances may be used as peeling agents.
Their effects may be different, varying from light to medium
and deep regeneration, depending on their strength, concen-
tration and depth of penetration. A number of different fac-
tors, however, including skin priming and cleansing, skin
type, anatomic location, volume and coat applications, as
well as exposure time to peeling agent and its pH, may influ-
ence peeling penetration [3, 4]. All of these factors should be
considered before performing any peeling procedure, in
order to identify the more appropriate peeling agent.
2 History
Chemical peeling is probably one of the oldest cosmetic pro-
cedures. Ancient treatments from the Egyptian age used
abrasive masks of alabaster particles as well as fermented
grape skins bathed in sour milk [5]. Women of ancient Rome
used to rub their skin to enhance their beauty. Both Egyptians
and Romans unknowingly benefitted from the superficial
A. Tedeschi, MD • D. Massimino, MD
U.O.C. di Clinica Dermatologica, Università di Catania,
Catania, Italy
G. Fabbrocini, MD
Dipartimento di Patologia Sistematica, Sezione di Dermatologia,
Università di Napoli Federico II, Naples, Italy
G. Micali, MD (*)
Dipartimento di Specialità Medico-Chirurgiche, Università di
Catania, Catania, Italy
e-mail: gmicali1@hotmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_74
exfoliation of hydroxyacids. Afterwards, poultices of mus-
tard, sulphur and limestone were used for the same purpose.
Women from India used a mixture of urine and pumice to
cause superficial exfoliation, while Turkish women merged
their skin with fire to obtain similar results.
Dermabrasion was also popular in ancient Egypt as phy-
sicians used sandpapers to treat scars. The first dermatolo-
gist who introduced the concept of peeling was Fox in 1871,
who described the use of 20 % phenol to lighten the skin [6].
Ten years later, Unna described the properties of other peel-
ing agents beside phenol, such as salicylic acid, resorcinol
and trichloroacetic acid. The first scientific paper reporting
the use of phenol peel to treat acne scars was published in
1952. Later in 1972, Bake and Gordon further studied this
agent, describing more in detail its beneficial effects.
Another peeling agent, tricholoroacetic acid, became popu-
lar during the 1980s.
3 Classification
According to the level of penetration, chemical peelings are
classified into [1, 7]:
1. Very superficial (Glycolic acid 30–50 %, Jessner solution
applied in 1–3 coats, Salicylic acid 25 % applied in 1
coat, Resorcinol, 20 % applied briefly (5–10 min),
Trichloroacetic acid (TCA), 10 % applied in 1 coat), in
which exfoliation is confined to the stratum corneum,
with no alteration below it
2. Superficial (Glycolic acid, 50–70 % applied 3–10’;
Salicylic acid 25 % applied in 4–10 coats, Pyruvic acid
40 % applied in 4–5 coats, Jessner solution applied in
4–10 coats; Resorcinol, 40 % applied for 30’ to 60’;
Trichloroacetic acid, TCA 20 %), when part of or all epi-
dermis is involved
3. Medium (TCA 35 %, Pyruvic acid 50–60 % applied in
several coats, Augmented TCA (Glycolic acid 70 % + TCA
1095
1096
35 %, Jessner solution + TCA 35 %, Salicylic acid + TCA
35 %), involving both epidermis and papillary dermis
4. Deep (TCA 50 %, Phenol), involving epidermis, papillary
and reticular dermis
The effect of very superficial and superficial peelings con-
sists of limited exfoliation, involving the upper part or the
epidermis in toto, with no effect on the dermis. They do not
require any particular post-treatment procedures afterwards
and are associated with very low risk of side effects. Rarely,
mild to moderate erythema can be observed in limited areas.
However, the reaction disappears spontaneously within a few
days. Superficial peels are commonly used to treat inflamma-
tory acne, mild photoaging (Glogau I-II) and mild skin
hyperpigmentation.
Medium-depth peelings involve epidermis and papillary
dermis. They may cause protein denaturalization, clinically
appearing as skin bleaching (frosting), and stimulate histo-
logic modifications in connective tissue with new deposition
of collagen and elastic fibres. These peels are mainly indi-
cated for the treatment of actinic keratoses, moderate photo-
aging, mild acne scars and hyperpigmentations [3, 4].
Deep peelings cause a significant dermal injury, involving
the reticular layer. They also cause a quick and intense frost,
resulting in dermal regeneration with new deposition of col-
lagen and glycosaminoglycans. If not properly applied, this
type of peeling may be responsible for severe complications,
which may require specific treatments. The main indication
of deep peelings is severe photoaging.
The choice of the appropriate peeling is very important in
order to avoid mild or unsatisfactory results in case of inad-
equate superficial peelings, or difficult-to-handle side effects
resulting from overtreatment, or in case of unnecessary deep
procedures.
4 Indications
The main indications of chemical peelings include acne and
acne scars, chrono and photoaging (fine lines under the eyes
and around the mouth and wrinkles caused by sun damage,
aging and hereditary factors) and skin hyperpigmentation
(spots, freckles and melasma). Actinic keratosis and lentigo
can also be successfully treated with peeling.
Acne is a chronic cutaneous disorder of the hair follicles and
sebaceous glands, characterized by polymorphic lesions which
appear in areas with a high concentration of sebaceous glands
(face, chest, upper back, shoulders and neck). It usually devel-
ops during adolescence, but it can affect any age group.
Clinically, it is characterized by non-inflammatory follicular
lesions (microcomedones, closed and opened comedones),
inflammatory follicular lesions (papules, pustules and nodules),
scars (atrophic, hypertrophic) and hyperpigmented lesions.
A. Tedeschi et al.
Acne scars, in particular, can be classified into three main
types: icepick, rolling and boxcar. Icepick are small scars
(<2 mm) that extend vertically to the deep dermis or subcu-
taneous tissue. Rolling scars extend to the dermis and give
the skin a wave-like appearance. Boxcar scars are oval/round
depressions with marked edges similar to chickenpox scars,
which can be either superficial or deep. Based on another
classification, acne scars can be divided into elevated, dys-
trophic and depressed. The former are subdivided into hyper-
trophic, keloidal and papular, while the latter are subdivided
into stretched and non-stretched scars [8, 9].
Chronoaging refers to the physiological decline of skin
appearance and functions depending upon both genetic fac-
tors and lifestyle (excess alcohol consumption, tobacco
abuse, environmental pollution, body weight). Within the
skin, aging is associated with a loss of fibrous tissue, slower
rate of cellular renewal and a reduced vascular and glandular
network. Barrier function that maintains cellular hydration
also becomes impaired. The subcutaneous tissue (hypoder-
mis) flattens, particularly in the face, hands and feet.
Photoaging is an extrinsic skin damage mainly resulting
from a chronic ultraviolet exposure and infrared irradiation
from the sun. The clinical appearance of photoaged skin is
characterized by fine and coarse wrinkles, roughness, laxity,
pigmented spots and telangiectasia (dilated blood vessels).
These cutaneous manifestations, particularly when extensive
or severe, could be responsible for subsequent skin tumours
[10]. Cellular damage is caused by cumulative sun exposure
and, therefore, located at the visible areas of the body such as
face, neck, cleavage (low neck line), hands, arms and legs.
Spots are large flat brown spots on the face and hands aris-
ing in middle age people and resulting from sun damage
exposure. Unlike freckles, they tend to persist for long peri-
ods and do not disappear in the winter.
Freckles are small flat brown macules arising on the face
and other sun-exposed areas, particularly during summer.
They are most often seen in fair skinned people, and occa-
sionally, darker skin types as well. The colour is due to local-
ized accumulation of melanin in keratinocytes.
Melasma is an acquired disorder of the skin characterized
by light to dark brown pigmentation on photo-exposed areas.
It occurs most commonly in women who are pregnant (“chlo-
asma”) or take oral contraceptive pills and live in sunny
areas. The exact cause is unknown but hereditary, hormones
and sunlight exposure are important factors. Clinically, it is
possible to distinguish three main patterns: centre facial,
malar and mandibular [12].
Actinic keratosis is a frequently encountered premalignant
UV light-induced lesion of the skin occurring in areas exposed
to sunlight mainly in fair-complexioned elderly or middle-
aged people. Lesions can progress to chronic disease and are
usually multiple, characterized by small scaly bumps (measuring
from a few millimetres to slightly over 2 cm in diameter),
Chemical Peel
rough to the touch and brownish in colour. Sometimes, they
appear as scaly atrophic and erythematous lesions.
The appearance of an erythematous halo (even in small
lesions) and infiltration around the base may indicate carci-
nomatous transformation.
Solar lentigo is a benign pigmented lesion commonly
observed in fair-skinned people on sun-exposed areas (neck,
hands, and forearms). It usually occurs between the fourth
and sixth decades of life. The lesions are characterized by
round or oval, irregularly shaped hyperpigmented macules,
varying in size from a few millimetres to 1 cm or more. The
colour varies from yellow-brown to dark brown.
5 Patient Evaluation
Patient’s pre-treatment evaluation is very important. In fact, the
satisfactory results of chemical peels depend not only on the
physician’s ability but also on the correct selection of patients,
as well as on the adequate choice of the peeling agent [13].
Some skin-related factors, such as age, sex, skin type,
aging and photoaging severity and any psychological dis-
comfort or other skin disorders, must be considered in the
peeling choice. Moreover, patient’s history of abnormal or
keloid scarring, perioral herpes simplex virus (HSV) infec-
tion, prior treatments such as oral isotretinoin, radiation, or
laser skin resurfacing and photosensitizing medications
should be carefully evaluated as well, in order to avoid scar-
ring or slow re-epithelialisation.
As regards skin type and colour, they should be accurately
examined in order to prevent post-treatment abnormal pigmen-
tation: thicker and sebaceous oily skins are more resistant to
peeling, and therefore require a deeper treatment than other
skin types; skin types IV–VI, according to Fitzpatrick’s classi-
fication, are not indicated for medium to deep peeling because
of high risks for pigmentary hyper or hypopigmentation.
Anatomic localization is important as well, since those
areas where adnexae are more represented, such as the face,
have a faster re-epithelisation compared to others. The dif-
ferent thickness of the stratum corneum should also be con-
sidered. More sensitive areas, such as the periorbital skin,
require lighter treatments compared to forehead and glabella.
Furthermore, concomitant disorders, such as atopic dermati-
tis, seborrheic dermatitis, psoriasis, contact dermatitis or
rosacea must be carefully considered for their potential exac-
erbation in the post peeling period.
Skin aging, according to Glogau’s classification (Table 1),
should be evaluated as well. In particular, patients in category
I with mild photoaging can be treated successfully with light
chemical peelings, while those in the remaining categories
may better benefit from medium-depth peelings [2–4, 14, 15].
In patients with a history of herpes simplex, a correct pro-
phylaxis with antiviral drugs from the prepeel period until
1097
Table 1 Glogau classification of photoaging
Type I: early photoaging
1. Mild pigmentary changes
2. No keratoses
3. Minimal wrinkles and/or acne scarring
4. Patient age: 28–35 years
5. Little or no make-up
Type II: early to moderate photoaging
1. Minimal dyschromias (senile lentigines)
2. Early actinic keratoses
3. Slight lines near the eyes and mouth; mild acne scarring
4. Patient age: 35–50 years
5. Need for some make-up
Type III: advanced photoaging
1. Discoloration with teleangectasia
2. Visible actinic keratoses
3. Persistent wrinkles; moderate acne scarring
4. Patient age: 50–65 years
5. Need for heavy make-up
Type IV: severe photoaging
1. Yellow or grey skin
2. Actinic keratoses with or without skin malignancies
3. Wrinkles throughout; severe acne scarring
4. Patient age: 60–75 years
5. Make-up cakes and cracks with poor coverage
complete re-epithelisation is indicated, especially when
medium-depth or deep peelings are performed [2, 16].
Patient’s lifestyle should always be evaluated in order to
treat patients able to avoid sun exposure and to use sun-
screens, for a period varying from 15 days to 6 months if
superficial and medium-depth or deep peelings, respectively,
are performed. In case of persisting erythema, patient should
also be able to use camouflage to disguise the anaesthetic
problem.
Finally, subjects with significant history or current evi-
dence of any psychological discomfort or with immunocom-
promising diseases or allergies should not be treated.
6 Skin Priming
Skin priming is necessary to improve peels results. It allows
an easier and uniform penetration of the peeling agent,
reducing duration of the re-epithelisation and minimizing the
risk of post-treatment hyperpigmentations.
It consists in the topical application of some compounds,
such as retinoic acid 0.05 %, glycolic acid 10 %, pyruvic
acid 7 % and hydroquinone 4 %, used alone or in combina-
tion with others, for at least two weeks before the treatment.
They cause a superficial exfoliation, due to keratinocyte dis-
cohesion, and allow a more uniform, faster and deeper pen-
etration of the exfoliating agents due to epidermal thinning.
1098
7 Peeling Complications
Peeling complications represent a question of matter which
needs to be carefully considered before performing a peeling and
whose frequency is directly related to the peeling depth. Thus,
deeper treatments show many potential complications [1, 14].
Most frequent complication is represented by pigmentary
changes. Among these, hyperpigmentation is the most com-
mon one, but hypopigmentation is also observed, especially
in case of deep peel. Although pigmentary changes can occur
after any depth of peeling and can involve all Fitzpatrick skin
types, patients undergoing medium-depth peeling and with
higher phototypes (IV–V) are at a greater risk [15]. Early sun
exposure is considered to be responsible for this inconve-
nience, together with other possible causes including over-
mentioned higher phototypes and oral contraceptives use [7].
Total sun blockers, used daily after peeling treatment,
together with a topical combination of hydroquinone 4 %
and retinoic acid 0.1 %, used both as skin priming and after
the procedure, may prevent this side effect [14, 17].
Scarring represents a relevant complication possibly occur-
ring when deep peelings are performed. Atrophic scars, hyper-
trophic scars or keloids may occur [7]. Patient’s pre-treatment
evaluation is extremely important in order to investigate a his-
tory of poor healing or keloid formation. Moreover, particular
care could be reserved in dark skinned patients that are at
higher risk for scarring. Scars are most commonly located on
the lower part of the face and on the perioral region, probably
due to the mechanical stretching occurring in this area during
eating and speaking. Lower eyelid ectropion has also been
observed from 3 to 6 months after phenol peeling [18].
Herpes simplex infection represents a frequent complica-
tion. Its outbreaks in patients with a history of HSV recur-
rences undergone medium-depth peeling may be prevented
with the prophylactic use of oral antiviral medications, begin-
ning 1–2 days prior to the treatment and continuing for 4–5
days after. The 400 mg oral dose, used 3 times daily, is usu-
ally a good prophylaxis but in case of outbreak, 800 mg orally
3 or better 5 times daily are indicated until complete re-epi-
thelization is done. Valacyclovir or famciclovir 500 mg orally
twice daily are also good alternatives. HSV prophylaxis is not
necessary for superficial peelings [15]. Bacterial infections
are not so common. Among them, Pseudomonas infection
represents the most dreadful one, especially in case of deep
peeling, because of potential pigmentary changes [19]. Other
possible pathogens, which need to be properly treated, include
Staphylococcous, Streptococcous and Candida infections.
Persistent erythema is considered a physiological event
consisting in skin remaining erythematous for up to 3 weeks
after the peeling. Erythema is due to angiogenic factors stim-
ulating vasodilatation, including fibroplasia process [3].
When erythema persists for more than 3 weeks and is associ-
ated to itch, it could be suggestive of possible scarring
A. Tedeschi et al.
formation, requiring potent topical corticosteroids, systemic
steroids and intralesional steroids. Silicone sheeting or pul-
sating dye laser represent other therapeutic options, espe-
cially in case of evident thickening or scarring [1, 3].
Milia may occur after a period of 8–16 weeks from the
procedure, probably due to greasy and occlusive post-peeling
treatments.
Acneiform eruption may be observed in a small percent-
age of patients during reepithelization phase or immediately
after, due to an exacerbation of pre-existing acne-prone skin
or overgreasing of the skin during the post-peeling period
[14]. Systemic antibiotics are usually administered to obtain
satisfactory results.
Allergic reactions are relatively rare and most commonly
associated with the use of resorcinol. They could be of diffi-
cult evaluation and misdiagnosed as their clinical presenta-
tion (erythema, itch, oedema) resembles normal post-peeling
reactions. Antihistamines together with steroids are usually
used to manage these complications.
Cardiotoxicity is an exclusive potentially severe compli-
cation occurring during phenol peeling. In particular, it has
been demonstrated that phenol can be responsible for cardiac
toxicity, including tachycardia (arrhythmia), premature ven-
tricular beats, bigeminy, atrial and ventricular tachycardia
[14, 20], as well as liver and kidney side effects [18]. For
these reasons, this kind of peeling must be performed only
by qualified physicians in an operating room with a cardio-
pulmonary monitoring of the patient [14].
8 Superficial Peelings
8.1 Glycolic Acid
Alpha-hydroxy acids (AHAs) are a group of carboxylic acids,
characterized by a hydroxyl group attached to the alpha posi-
tion of the carbon atom; by increasing epidermal thickness and
dermal glycosaminoglycan content, these substances have
been used for the treatment of several dermatological disor-
ders such as photoaging, acne, pigmentary and keratinisation
disorders. Glycolic acid represents one of the most commonly
used AHAs. It is used both in topical compounds, at low con-
centrations (5–20 %) and as a peeling agent at concentrations
up to 70 %. Because of its small molecular weight and size, it
has a high skin penetration ability. It is considered a relatively
safe, effective and well-tolerated peeling agent. It causes a
superficial peeling with few complications, although dermal
wounds similar to those caused by 40 % TCA have been
reported with the use of higher concentration (70 %) or in case
of prolonged exposure [2, 7]. Neutralization with any alkaline
solution (generally sodium bicarbonate 8–15 %) is required
after glycolic acid peeling, in order to avoid further penetra-
tion through the deeper skin layers [21]. Glycolic acid has
Chemical Peel 1099

a b

c d

Fig. 1 Glycolic 70 % peel in photoaging. Preoperative appearance: (a) Front. (b) Side. Postoperative appearance: (c) Front. (d) Side

been demonstrated to be effective for the treatment of acne
lesions (comedones and pimples), in which it may be used in
association with retinoic acid 0.05 %, applied daily up to 15
days before the procedure. Glycolic acid peeling, according to
its ability in causing smoothing and skin lightening, is also
indicated for melasma, photoaging (Fig. 1a–d), wrinkles and
actinic keratosis. If necessary, treatment can be repeated
within 3–4 weeks for a total of six treatments. Few precautions
are recommended before performing a glycolic acid peeling.
First of all, skin should be cleansed with a gentle cleanser, fol-
lowed by the application of a degreasing agent, such as ace-
tone or isopropyl alcohol, in order to remove any surface oils
and increase the penetration of the peeling agent. Finally, the
acid is applied using a cotton ball or a small brush, proceeding
from the forehead, where the skin is thicker, to the rest of the
face. Particular care should be taken for vulnerable areas, such
as nasal ala, lips, lateral canthus and oral commissures that can
be protected with an ointment [22]. When erythema appears,
the peeling needs to be neutralized with a solution of sodium
bicarbonate that causes a lot of fizzing. Later on, moisturizers,
emollients and sunscreens must be applied for 5–7 days during
the healing process. No particular care is required except that
cream containing alpha-hydroxyacids should be avoided for
2–3 days following the procedure.
8.2 Mandelic Acid
Mandelic acid is an alpha-hydroxy acid (AHA), derived
from almonds. Based on its large structure, it penetrates the
epidermis slowly and uniformly resulting in an ideal treat-
ment for sensitive skins affected by mild acne and abnormal
pigmentation. As a peeling agent, it is used at concentration
of 30 % or 50 %, alone or in combination with other agents
[23]. Mandelic acid causes a progressive, slightly furfural
exfoliation, with scarce evidence of post-treatment burn or
reddeness and low risk for hyperpigmentation. As a consequence
of its minimal photosensitizing activity, in many countries it
1100
is considered as a “summer peeling” or as a “peeling for
everyone in every season”, and can, therefore, be applied on
patients with higher Fitzpatrick skin types.
8.3 Retinoic Acid
Retinoic acid or tretinoin is a vitamin A’s synthetic derivative,
commonly used for the treatment of acne and photoaging,
because of its ability to thin the epidermis and increase der-
mal collagen content, resulting in a visible improvement of
skin appearance [24]. Topical retinoic acid, available in cream
at concentrations varying from 0.05 to 0.01 %, is frequently
used as skin priming agent especially for TCA or AHA peel-
ings, so to make a more uniform penetration of the chemical
agent. In addition, its use is suggested during the postpeeling
period, immediately after the reepithelization phase, to main-
tain the results [19]. Despite the beneficial effects, retinoid
acid has both a local irritating effect, including erythema,
scaling, dryness, burning and a photosensitizing activity. It is
therefore of extreme importance to evaluate optimum con-
centration, frequency and duration of drug applications.
Tretinoin peeling is a solution of tretinoin at high concen-
tration, varying from 1 to 5 %, in propylene glycol. It is applied
by gauze or brush in one or two coats, usually colouring the
skin in yellow, and it is left for 4–8 h [14, 24, 25]. After this
time, it is removed with water. The procedure is completely
painless and can be repeated after 2–3 days [24] or weekly
[25]. It is better to perform this peeling in the afternoon or in
the evening since retinoic acid is a photosensitive compound.
Women in any state of pregnancy must avoid this procedure,
while its use in patients with teleangectasia is still controver-
sial, probably due to the strong erythema that may result. This
peeling is mainly indicated in melasma, actinic changes and
poikiloderma of Civatte [14].
a b
Fig. 2 Salicylic 30 % peel in
acne. Preoperative (a) and
postoperative (b) appearance
A. Tedeschi et al.
8.4 Salicylic Acid
Salicylic acid is an organic carboxylic acid with a hydrox-
ylic group in beta position [14]. Unlike AHAs, salicylic
acid has a lipophilic structure which enables its penetration
through sebaceous glands and corneous cells with conse-
quent destruction and exfoliation of the upper layers of the
epidermis [26]. It can be used both as a topical compound
or a peeling agent. Low concentrations (0.5–10 %) [22] are
used in home topical preparations to treat mild acne, ich-
thyosis and plantar warts, while higher concentrations (20–
30 % in hydroethanolic or polyethylene glycol vehicle
(PEG), or 50 % in ointment) are used as a superficial peel-
ing agent [14, 27, 28]. It can be applied on all Fitzpatrick’s
skin types with no sedation or anaesthesia. Overpeel and
adverse reactions are not common [29]. Before performing
a salicylic acid peel, the skin should be prepared and
cleansed such as for the other peels. After its application
with cotton tips or brush, the peel is left on the face for a
few minutes (3–5) until the alcoholic component has evap-
orated and a subtle whitish powder layer has formed. At
this point, the peeling can be removed with no neutraliza-
tion [28, 29]. Moisturizers and sunscreens should be sug-
gested for 7–15 days or until healing phase is completed.
This procedure may be repeated every 4 weeks and usually
six treatments are required. The results are usually observed
after three treatments. Patients must be informed about a
light to mild burning sensation occurring during the treat-
ment and of potential scaling [2, 15]. Patients suffering
from salicylates allergy cannot receive salicylic acid as a
peel treatment [2, 28]. The main indications of salicylic
acid peels are represented by superficial to medium acne
scars, particularly those with a remarkable hyperchromic
component; inflammatory acne (Figs. 2a, b and 3a, b), rosa-
cea, melasma and photoaging.
Chemical Peel
a 8.6
b suggest to leave on the skin for 60–120 min [1]. After the
Fig. 3 Salicylic 30 % peel in acne. Preoperative (a) and postoperative
appearance (b)
8.5 Yellow Peel
Yellow peel (YP) is a combination of retinoic acid in high con-
centration and three different skin lightening substances,
including phytic acid, kojic acid and azelaic acid, which block
the synthesis of melanin at different levels. Vitamin C, bisabo-
lol and salicylic acid are anti-oxidant and anti-inflammatory
agents contained in this formulation as well. The name of this
peel is due to the particular yellow coloration of the skin after
its application. After skin preparation and degreasing as previ-
ously described, YP allows a sort of modulating peeling involv-
ing both superficial and medium epidermis. Furthermore, it
induces new epidermis regeneration with few risks for poten-
tial dischromia. Yellow peel is applied with fingers, left for an
average of 20–30 min and finally removed washing the face. At
the same time, moisturizers and sunscreens may be applied as
for other peels. Melasma and hyperpigmentations in general,
represent its main indication, along with superficial wrinkles
and acne post-inflammatory hyperpigmentations [30].
1101
Resorcinol Peel
Resorcinol or m-hydroxybenzene is a compound structur-
ally and chemically similar to phenol [29]. It is used in
concentration ranging from 10 to 30 to 50 % [1], (based
respectively on Unna’s eighteenth century and later
Lettesier’s modified formulation) [31] to obtain a power-
ful caustic action. Its efficacy as a reducing agent depends
on its ability to break keratin bonds, as well as to induce
both the epidermal regeneration and dermal fibroblasts pro-
liferation. Resorcinol is usually applied on the skin with
a spatula. As regards its application, some authors recom-
mend to leave it for a starting time of 25 min, increasing
5 min each week, for a total of 35 min [29], while others
remaining paste has been removed, the skin appears such as
after a first-degree burn and it exfoliates for the following
7–10 days. Post-peel care with antibiotic and corticosteroid
creams together with sunscreen use is important to limit
any possible complications (pigmentary changes, systemic
toxicity and allergic reactions). The main indications of
resorcinol peeling are represented by acne, including com-
edonic acne, along with pigmented lesions and superficial
scars [1]. It is a safe and painless peeling. Anyway, allergic
reactions may occur in some cases.
8.7 Jessner’s Solution
Jessner’s solution (JS) is a combination of different chemi-
cal substances, including salicylic acid (14 g), resorcinol
(14 g), lactic acid (85 %, 14 g) and ethanol (95 %, up to
100 ml), which can be used either alone for superficial
peeling or in combination with other agents to make easier
medium-depth procedures [1, 25]. Its efficacy in the treat-
ment of comedonic and inflammatory acne and dyschro-
mias depends both on a keratolytic and an anti-inflammatory
activity [2, 7, 29]. In particular, it causes keratinocytes dis-
cohesion, together with intra- and intercellular oedema.
Jessner’s specific formulation and dosage combine the
benefits of an exfoliating effect with few risks. JS is usu-
ally applied in two to three coats with wet gauze, sponges
or hair brush. The application of the solution is typically
accompanied by mild erythema and an intense burning
sensation, followed by a faint frost presenting as a skin
whitening with a dust-like aspect. Neutralization is not
required. Post-peel exfoliation usually occurs within few
days and may persist for up to 8–10 days [29].
1102
9 Medium-Depth and Deep Peeling
9.1 Pyruvic Acid Peel
Pyruvic acid (PA) is an alpha-ketoacid used as a superficial
to medium-depth peeling agent with keratolytic, antimicro-
bial and sebostatic properties [6, 11, 29, 32]. Pyruvic acid is
referred as a potent acid because of its comparatively low
pKa (acid dissociation constant. It expresses the equilibrium
constant for the reaction in which a weak acid is in equilib-
rium with its conjugate base in aqueous solution. Therefore,
the smaller the value of pKa, the stronger the acid) (2.39),
compared to other chemical substances. Its relatively small
molecular structure as well as the presence of a ketonic group
instead of the hydroxyl one improves its penetration to the
pilo-sebaceous unit. Pyruvic acid efficacy primarily relies on
its keratolytic, antimicrobial and sebostatic properties.
Moreover, it stimulates the formation of new collagen and
elastic fibres as well as glycoproteins at the upper papillary
dermis [6, 29, 33]. It is commonly used in concentrations
ranging from 40 to 70 % in water/ethanol solution to perform
medium-depth peeling, with fewer side effects respect to
other medium-depth peelings. However, the acidity of PA
influences both its efficacy and absorption and its side
effects. A new formulation with lower pH of PA provides in
an increased absorption with less discomfort compared to
the older one [6, 33]. After degreasing the skin with alcohol,
the acid can be applied with gauze or cotton-tipped applica-
tor. The action of pyruvic acid continues until it is neutral-
ized with an alkaline solution (sodium bicarbonate). Pyruvic
acid peel is usually associated with intense burning sensation
and erythema, which lasts for a few minutes. Patients may
also present a mild desquamation following the treatment.
However, healing is completed within 5–7 days. The main
indications of pyruvic acid are inflammatory acne, moderate
acne scars, seborrheic skin, actinic keratoses, warts and early
to moderate photodamaged skin (fine wrinkles, diffuse dys-
chromias and mottling) [6, 32, 33].
9.2 Trichloroacetic Acid
Trichloroacetic acid (TCA) is a traditional chemical substance
which has been widely used over the past 20 years for both
superficial and medium-depth as well as deep peelings, at con-
centration ranging from 10–20 % to 35–50 % respectively [7,
15]. However, concentrations higher than 35 % are not sug-
gested because of their potential scarring. To obtain the 50 %
TCA results, a combination of 35 % TCA with other peeling
agents such as Jessner’s solution (Monheit method), 70 % gly-
colic acid (Coleman method) and solid carbon dioxide (Brody
method) can be used [14, 34]. TCA peel is indicated especially
in photoaging and hyperkeratotic lesions. The procedure is
A. Tedeschi et al.
painful and requires 10–15 min [1]. Although well tolerated in
most cases, it sometimes needs topical anaesthesia [1] or sys-
temic sedation. Skin priming, 15 days before performing the
peel, is important to obtain a uniform as well as faster and
deeper penetration with successful results. Cleansing and
degreasing, as for other peels, are thus essential before TCA
application. Trichloroacetic acid can be applied with cotton
tips or small gauzes, according to the cosmetic units, begin-
ning from forehead. Peeling depth is easily monitored by ery-
thema and frosting degrees. Thus, minimal erythema represents
a very superficial peeling, involving mostly the stratum cor-
neum, while mild erythema with light frosting patches corre-
sponds to superficial peeling, causing 2–4 days exfoliation’s
period. The white frost with a background of erythema shows
a medium-depth peel while the solid white frost is indicative
of a deep peel, extending down the papillary dermis [1, 7, 14].
If TCA is applied in several coats, a deeper peeling is obtained.
In this case, it is better to use lighter concentrations. An intense
burning sensation is typical of TCA peelings and requires the
use of wet cold compresses at its end. After the procedure, a
cream or ointment with 1 % hydrocortisone may be applied to
sooth the skin. As regards the post peeling phase, it should be
recommended to avoid heavy exercise, sweating and touching
the face in the period immediately after the peeling. Sun expo-
sure must be avoided as well for 4–5 months later. Patients
should be informed about their darkening skin colour and
potential swelling. The exfoliation usually begins 3–4 days
after the peeling, starting at the perioral and periorbital area to
end at the forehead. The scales in this period should not be
removed to avoid post-inflammatory hyperpigmentation. If
erythema persists for 2 or 3 weeks after exfoliation, the use of
light corticosteroid cream or zinc oxide paste is suggested.
TCA is variably responsible for changes in epidermal
thickness, epidermal and dermal proteins denaturation as well
as coagulative necrosis, resulting in epidermis revitalization,
increase of both fibroblasts and collagen type I and III and
reduction of the elastic component [1, 2, 35, 36]. Trichloroacetic
acid solution is obtained as a weight to volume preparation in
a small amount of water. It is not remarkably expensive, stable
at room temperature, not light-sensitive and does not need to
be neutralized [14, 37]. TCA best results have been obtained
in aging and photoaging, particularly in patients with photo-
type II and, less commonly, III and IV [34]. It also has been
demonstrated to be effective at treating actinic keratosis, solar
lentigines and acne scars (Fig. 4a, b) [15, 38].
9.3 Combination Peelings
They are used to make deeper treatments with fewer complica-
tions. In this case the first peeling agent causes a superficial
peeling so to allow a faster and deeper penetration of the second
one. The most common combination peeling include Monheit,
Chemical Peel
Fig. 4 TCA 35 % peeling in
a b
acne scars. (a) Preoperative view.
(b) Postoperative view
Coleman and Brody combination that respectively use as first
agent Jessner solution, 70 % glycolic acid or solid carbon diox-
ide to obtain results equal to 50 % TCA concentration. TCA
35 % is the second peeling agent. In the Monheit’s combination,
JS is applied in several coats to obtain erythema and patched
frost. TCA is applied immediately after or 5 min later. In
Coleman’s combination glycolic acid at 70 % is applied for
2 min, while TCA is applied after GA neutralization. The
Brody’s combination foresees the pre-treatment of the area with
solid carbon dioxide applied in a solution of acetone so that the
solid CO2 ice can be freely spread over the skin [3, 34]. All TCA
combination peels have been demonstrated to be more effective
than TCA 50 % alone and to preserve its safety [15].
9.4 Phenol
It is one of the oldest agents, discovered by McKee, used for
medium to deep peelings to successfully treat post-acne
scarring and cutaneous photoaging [14]. Phenol is the proto-
type of deep peeling. It produces keratolysis and keratoco-
agulation, reticular dermis damages followed by production
of new collagen, resulting in both clinical and histological
improvement [18]. Phenol as a peeling agent may be used
alone or in combination with other substances, such as water,
vegetable oils, croton oil [14]. This last is a derivative of the
seeds of Croton tiglium and acts as a vescicant epidermolytic
agent, increasing the penetration of phenol [34].
1103
Phenol chemical peeling can be performed with two dif-
ferent modalities: unoccluded and occluded Baker and
Gordon’s formula. Occlusion is usually obtained with the
application of a waterproof tape for 48 h which enhances its
penetration [3, 34]. Interestingly, the use of higher concen-
trations of phenol (i.e. 88 %) is not related to a deeper pene-
tration because of its keratocoagulant activity which limits
its effects. Thus, phenol as a deep agent is commonly used as
a solution of 45–55 % [2, 4].
Phenol peeling should be performed exclusively by well-
trained physicians in an operating room. Since phenol causes
pain for 15–20 s after its application and may be responsible
for severe discomforts, the administration of sedatives and
analgesics is recommended. Also, it requires preoperative
intravenous hydration together with a close cardiopulmonary
monitoring of the patient and phenol serum level evaluation
in order to prevent potential systemic side effects [4, 34].
Before administrating the peeling, the skin is cleansed and
degreased with acetone. Phenol is then applied in subsequent
stages with cotton-tipped applicators, starting from the fore-
head to all aesthetic units, producing a uniform white frost
[4, 34]. To minimize systemic toxicity, applications are
15–20 min delayed from each other. In case of occluded pro-
cedure, the skin is covered with a waterproof dressing and
left for about 48 h. Afterwards, the face will be cleaned with
sterile saline solution or hydrogen peroxide and variably
covered with antibiotic creams, moisturizers and occlusive
dressings [14, 34].
1104
Phenol peeling’s main indications are aging and photoag-
ing, especially in fair skin patients, acne scars, actinic kera-
toses and solar lentigines [14, 34].
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(1999) The use of chemical peelings in the treatment of different
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(2004) Pyruvic acid peels for the treatment of photoaging. Dermatol
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 Advances in Facial Plastic Rejuvenation
with Ablative Laser Technology: Can
Clinical Results Be Tailored Based
on Histology Effects?
Mario A. Trelles
CO2 laser ablative resurfacing significantly rejuvenates aged
facial skin, but the burn-related post-operative symptoms take
many weeks to recover from and treatment is not complication-
free [1]. The CO2 fractional mode, offered as an alternative for
full ablative resurfacing, shortens recovery time, and this treat-
ment approach produces milder post-operative symptoms and
has fewer complications, and additionally, patients do not
require a long period of downtime from work [2].
The CO2 fractional mode of resurfacing is thus an attrac-
tive method for skin rejuvenation. If selection of the most
appropriate treatment programme in relation to histological
effects it produces could be linked with the clinical improve-
ment required, results could be better predicted and side
effects reduced.
In order to objectively ascertain both the histological
effects and clinical results, treatment was conducted on 16
patients, presenting various degrees of wrinkling, using a
CO2 laser in fractional mode.
Sixteen females, mean age 41 years, were recruited to
undergo one session of fractional resurfacing treatment. Four
subjects had degree I wrinkles, four had degree II wrinkles and
eight had degree III wrinkles. Wrinkles were classified accord-
ing to the Glogau scale. Skin phototype ranged from Fitzpatrick
II to IV. Areas selected for treatment were full face and the
upper lip. Skin condition, regarding wrinkle degree, skin pho-
totype and age, was matched as accurately as possible for the
various treatment groups and settings (Table 1).
No patient had previously undergone any laser treatment
or chemical peel and regularly used cosmetic products with-
out anti-pigmenting ingredients. Treatment was performed
with the fractional sequential mode of the CO2 Ultrapulse®
Laser Encore FX™ (Lumenis, Israel). Details of the treat-
ment were explained to all patients. A full explanation of the
M.A. Trelles, MD
Private Practice, Instituto Medico Vilafortuny, Antoni De
Gimbernat Foundation, Cambrils, Spain
e-mail: imv@laser-spain.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_75
expected treatment results was given, informing of the pos-
sible need for extra treatment, especially for those patients
presenting higher-degree wrinkles. All patients signed a
form of consent for surgery and use of clinical photography.
The Encore Ultrapulse® Active FX™ is a pulsed CO2
laser system equipped with a sophisticated control pattern
generator (CPG) which, under computer guidance, can fire
pulses in a sequential mode according to various programs.
The pattern can be selected from the many offered by the
computer. There is also the option of programming treatment
with nonsequential pulses. The selected design can be modi-
fied in size and the number of pulses per area and, in this
way, pulse density can be chosen. The laser emits at a fixed
pulse length of 350 μs. A high pulse density per area means
less space between pulses within the area of the pattern [3].
Pulse density programme #5 was used for treatment in
each of the 16 patients, corresponding to 52 pulses for a hex-
agonal pattern of size 5. The treatment energy programmed
was 150 mJ, corresponding to 11.3 J/cm2 at 11.3 W and a
pulse rate of 75 Hz, for all treatments, except for the eight
patients with degree III wrinkles, who were divided into two
subgroups of four patients each and were treated with the
same settings but using two different pulse rates, 2 upper lip
and 2 full face at 75 Hz and 2 upper lip and 2 full face at
175 Hz (Table 1). In this last case, the power of emission of
the laser was 26.3 W. Attention should be paid to the fact that
although the power of emission of the laser changes, the
amount of energy within the selected treatment pattern is
maintained at 20.8 J/cm2. Interestingly, the pulse rate was
varied for those patients divided into two subgroups, but all
other settings were maintained constant.
The aim of these different pulse rate settings for degree III
wrinkles was to determine whether there was any correlation
between the amount of residual thermal damage (RTD) in
tissue and clinical outcome, when varying the speed of
pulses. Histologies were examined in order to ascertain
whether there was any influence on quality of results related
to better collagen formation in correlation with possible dif-
ference in RTD and clinical outcome.
1105
1106 M.A. Trelles

Table 1 Characteristics of patient’s Fitzpatrick wrinkles, phototype and area treated as well as laser settings used
Laser settings 11.3 W, 150 mJ (11.3 J/cm2), 75 Hz pulse rate, density 5, hexagonal pattern
Phototype 4 patients Age 4 patients Age 4 patients Age
Degree I Degree II Degree III
II Upper lip 34 Upper lip 42 Upper lip 57
III Upper lip 38 Upper lip 48 Upper lip 54
II Full face 37 Full face 51 Full face 48
III Full face 36 Full face 53 Full face 56
Laser settings 26.3 W, 150 mJ (11.3 J/cm2), 175 Hz pulse rate, density 5 hexagonal pattern
Wrinkles 4 patients Age
Degree III
II Upper lip 55
III Upper lip 57
II Full face 49
III Full face 51

Fractional laser resurfacing was started 3 h after having
applied topical lidocaine EMLA anaesthesia (Laboratorio
Astra España, S.A., Esplugas de Llobregat, Barcelona,
Spain) with an occlusive dressing. Also, all patients received
1 g of paracetamol and 10 mg of Valium® orally, 45 min
before surgery.
At the time of treatment, the topical anaesthesia was
removed, the skin cleaned and the pattern was repeatedly
fired with laser pulses on the whole area of resurfacing.
Treatment was done in a single pass with no overlapping. As
the treatment progressed, especially in the case of full-face
resurfacing, discomfort, including pain, was noticed, but no
patient decided to curtail the treatment.
Once the selected area was treated (upper lip or full face),
biopsies were taken from all patients. In the case of upper lip
resurfacing, in order to avoid any possible aesthetic compli-
cations by taking a biopsy from the treated area, the same
settings were used for identical treatment on a small area of
the preauricular skin, and immediately after, an ellipsoidal
section skin biopsy was taken, which included part of the
treated and part of the non-treated skin. In the case of full-
face resurfacing, pre- and posttreatment biopsies were also
taken from the preauricular area. Histological check-up of
laser effects was carried out by an independent pathologist.
Samples were routinely processed and stained with hema-
toxylin/eosin and comparatively examined.
The pathologist reported in detail all changes noticed in
the tissue after treatment compared to samples before treat-
ment. A month after treatment, clinical outcome was evalu-
ated and the histologies were re-examined seeking a possible
correlation.
Upon completion of laser resurfacing, no occlusive dress-
ing was used, but flupamesone/gentamicin (Flutenal®
Gentamicina, Recordati España S.L., Madrid, Spain) was
recommended to be gently applied four times per day until
natural separation of the crusts occurred. Paracetamol
600 mg, every 6 h, was recommended during the first 3 days
and a local acyclovir cream was supplied for use on the ver-
million of the lip three times per day in all patients.
1 Results
Tissue healing time and post-operative skin signs for each
patient are presented in Table 2. In general, upon clinical
evaluation 1 month after surgery, results were very encourag-
ing. In all patients scabs started to fall off 5 days after resur-
facing. All patients appreciated their improved skin
condition, which presented a fine, new epithelium 8 days
after treatment (Fig. 1). The skin’s improved condition was
more noticeable in patients with degree I and II wrinkles.
Also, in those patients with degree III wrinkles that were
treated with higher pulse rate but with the same settings as
the rest of cases, skin appearance was better and residual
wrinkles were also less visible (Fig. 2). The external aspect
of skin rejuvenation was better in all cases and wrinkles were
less marked and the resurfacing effects were more evident in
those patients with lower degree wrinkles. No complications
were reported or noticed.
In patients presenting degree III wrinkles, there was a
clear correlation between the higher pulse rate used and the
results achieved regarding depth and aspect of the wrinkles,
although scabs took a few more days to fall off (Fig. 3).
Erythema was more evident in those cases of degree III
wrinkles treated with a faster pulse rate, but took no more
than 2 extra weeks to disappear. It was noticed that patients
with degree III wrinkles, when compared to those of
degree I and II wrinkles, did not seem to receive as much
benefit from the treatment. However, all patients treated,
regardless of the degree of their wrinkles, were satisfied
with the outcome. Erythema was easy to disguise with
colour make-up.
Advances in Facial Plastic Rejuvenation with Ablative Laser Technology: Can Clinical Results Be Tailored Based on Histology Effects? 1107

Table 2 Tissue healing time and post-operative skin signs

Patient Area treated Wrinkle degree Phototype Pain Edema Scab Erythema Healing time/days
1 Upper lip I II No Yes No Yes 4
2 Upper lip I III Yes Yes Yes Yes 5
3 Full face I II Yes Yes Yes Yes 5
4 Full face I III Yes Yes Yes Yes 5
5 Upper lip II II Yes Yes Yes Yes 4
6 Upper lip II III Yes Yes Yes Yes 6
7 Full face II II Yes Yes Yes Yes 4
8 Full face II III Yes Yes Yes Yes 5
9 Upper lip III II No Yes Yes Yes 5
10 Upper lip III III No Yes Yes Yes 6
11 Full face III II Yes Yes Yes Yes 6
12 Full face III III Yes Yes Yes Yes 5
13 Upper lip III II Yes Yes Yes Yes 7
14 Upper lip III III Yes Yes Yes Yes 7
15 Full face III II Yes Yes Yes Yes 8
16 Full face III III Yes Yes Yes Yes 9
Patients were examined 1 week after surgery to evaluate symptoms related to resurfacing and skin reepithelisation

a b

Fig. 1 (a) Before full-face Ultrapulse® Encore FX™ fractional resur- using a pulse rate of 75 Hz, density # 5 programme. Full skin recovery
facing on a 33-year-old female, phototype III, wrinkle degree I, present- and reepithelisation is observed with erythema. Skin looks fresher and
ing solar skin damage. (b) Twelve days after treatment, carried out no signs of solar damage are visible
1108 M.A. Trelles

a b

Fig. 2 (a) Upper lip resurfacing before treatment with high pulse rate treatment, skin looks totally recovered and with scattering of slight ery-
program. Skin phototype II in a 58-year-old female, degree III wrinkles. thema. Light wrinkle appearance is still noticed, but the aspect of the
Notice evident signs of skin ageing and wrinkles. (b) One month after skin is excellent with no pigmentary changes

a c

Fig. 3 (a) Before full-face Ultrapulse® Encore FX™ fractional resur- skin shows the typical aspect of the laser scanner pattern. (c) Total
facing in a 48-year-old female, phototype III, wrinkle degree II. (b) One recovery achieved 1 month after resurfacing. Improvement of the skin
day after treatment with standard settings, but at 175 Hz pulse rate, the condition is clear and wrinkles have practically disappeared

Biopsy skin samples before treatment displayed charac-
teristic signs of tissue ageing, being more pronounced in
higher-degree wrinkles. Elastosis was evident in a few cases,
but separation between fibres in the dermis was clearer in
degree III wrinkles. In degree I wrinkles, collagen fibres in
tissue appeared almost normal and well compacted and are
with narrow interfibrillary spaces. There was some flattening
of the epidermis. These characteristics in epidermis and der-
mis were better observed in samples corresponding to degree
II and III wrinkles (Fig. 4).
Advances in Facial Plastic Rejuvenation with Ablative Laser Technology: Can Clinical Results Be Tailored Based on Histology Effects?
a b
Fig. 4 Skin 125× HE/EO. (a–c) Correspond to samples of before
treatment, wrinkles degree I, II and III, respectively. Notice progres-
sive signs of skin ageing in direct correspondence to degree of
In histologies corresponding to after treatment for
degree I wrinkles, the epidermis was partially removed and
there were no images or RTD. In patients with degree II
wrinkles, histologies revealed total removal of the epider-
mis with no signs of coagulation in the dermis. The only
difference between the results of this programme also used
for degree III wrinkles was observed in samples of degree
III wrinkles treated with a high pulse rate but with the same
settings. A narrow band of RTD was noticed in the dermis.
A slight change in tissue morphology was shown by a
darker coloration, displaying a band of coagulation along
the resurfaced skin, representing changes in the dermal col-
lagen matrix (Fig. 5).
By increasing the speed of laser pulses, keeping the pro-
grammed power and pulse width stable and a fixed density of
pulses, the Encore Ultrapulse® Active FX™ fractional resur-
facing in sequential mode does make a significant difference
in tissue when treating degree III wrinkles, as observed in
histology samples. With the settings used in this study, total
epidermis elimination was noticed with higher pulse rate
speed. Action observed in tissue was clearly related to better
appearance of tissue and results of wrinkle treatment, which
was also perceived by patients.
Treatment at a higher pulse rate produced epidermis elim-
ination and RTD and would be the reason for more visible
and lasting erythema, which translates into more significant
neovascular formation [4]. In fact, RTD implies a band of
coagulation that will require an increased reaction during tis-
sue recovery, with active neovascular formation and also
with formation of new collagen fibres. However, a faster
1109
c
wrinkling. Degree III wrinkles show more evident sign of elastosis
with a thinner epidermis which is wavy compared with degree I wrin-
kle samples
pulse rate required a longer time for the skin to reepithelise
and recover from erythema. More consistent RTD has been
associated with better formation of collagen [5]. The more
evident band of coagulation left in the tissue after traditional
resurfacing has always been associated with a longer period
of time needed for the skin to recover and a higher risk of
scarring and complications, which in no case was observed
with fractional CO2 laser resurfacing in this study.
Slower recovery of the skin after fractional resurfacing in
these cases was compensated by a better treatment outcome
when compared to patients also presenting degree III wrin-
kles who obtained less evident results. This relation between
stronger treatment and longer period of recovery has also
been observed in conventional resurfacing treatments [6].
Pain during treatment was bearable, but degree III wrin-
kle patients complained more when a higher pulse rate was
used on them. Interestingly, no correlation was found
between skin phototype and side effects. All patients reacted
with about the same intensity of erythema and none suffered
any pigmentary changes. Skin healing was similar in all
degrees of wrinkles treated with the same settings but took a
few days longer when a high pulse rate was programmed.
The outcome of skin rejuvenation was better when the
degree of wrinkles was lower. Degree II and III wrinkles did
not react to treatment as evidently as degree I wrinkles, appar-
ently due to the fact that the laser settings used were the same
for all cases and should be adjusted, increasing parameters
when treating a higher degree of wrinkles. According to clini-
cal results and tissue effect as seen in histologies, an increase
in fluence (a higher density of pulses per area of the pattern)
1110
a b
Fig. 5 Skin 250× HE/EO. (a–d) Represent the skin histologies in rela-
tion to the four programme used for fractional resurfacing. (a–c)
Represent histologies of the same laser programme used for degree I, II
and III wrinkles, respectively. (d) Corresponds to same laser programme
together with a faster speed of pulses delivered will lead to a
more consistent tissue effect and better clinical outcome [7].
Patients who were interviewed once the skin had recov-
ered were satisfied with results of treatment, but those treated
for degree II and III wrinkles pointed out that they would like
to have obtained more evident rejuvenation effects. Higher-
degree wrinkles, especially those on the upper lip, as has also
been observed with conventional resurfacing [8], would
require more than one treatment session or a higher setting,
in which the speed of pulse delivery would play an important
role. A fast pulse rate implies less time for tissue to cool
down between the various pulses, and therefore, a steep pro-
file of heat accumulation in tissue is formed, with consequent
thermal propagation to neighbouring dermis and formation
of RTD.
Lateral propagation of heat will occur with the coagula-
tion phenomenon with tissue stimulation at the time of tissue
repair. Consequences of thermal deposit left in the dermis
will lead to inflammation and will prompt the wound healing
mechanism to proceed more vigorously, with enhanced for-
mation of neovascularity and new collagen fibres.
M.A. Trelles
c d
but with higher pulse rate delivery also used on patients in subgroup of
degree III wrinkles. Notice in samples (a) to (c) almost equal effect in all
cases with total elimination of epidermis but without RTD. The last
sample (d) shows evident epidermis removal and slight RTD in dermis
It is presumable, according to the findings of this study, that
high fluences delivered at a slow pulse rate in a low density
programme of pulses per area within the chosen pattern can
facilitate accurate tissue elimination with well-controlled ther-
mal effects, avoiding propagation. Following this hypothesis,
treatment of skin pigmentary disorders will also be candidates
for fractional CO2 laser elimination. However, prolonged fol-
low-up will also be advisable in order to see a later response of
pigmentation and its possible recurrence (Fig. 6).
Our observations support the possibility of tailored CO2
laser treatment settings according to skin condition and
degree of wrinkles in order to obtain the best results. Also,
treatment can be programmed according to patients’ avail-
ability, so that resurfacing can be conducted in only one or
various sessions.
The magnitude and extension of coagulation or RTD in
dermis should be adapted sufficiently to achieve “enough”
effects of skin rejuvenation and in accordance with patient
expectation. In correlation with characteristics of skin age-
ing, laser settings can be adapted, based on the effects that
are noticed in histological findings, as is the case of all
patients treated and tissue layers examined.
Advances in Facial Plastic Rejuvenation with Ablative Laser Technology: Can Clinical Results Be Tailored Based on Histology Effects?
a c
Fig. 6 (a) Before upper lip fractional pulsed CO2 laser resurfacing on
a 30-year-old female, phototype IV, presenting segmentary pigmenta-
tion on the upper lip. (b) Patient during treatment with the Ultrapulse®
Encore FX™ CO2 laser system. (c) Immediately after treatment, the
Conclusions
CO2 laser fractional resurfacing in sequential mode with
the Encore Ultrapulse® Active FX™ device obtains rapid
skin healing, with excellent control of side effects and
complications, regardless of skin phototype or degree of
wrinkles, provided the parameters used in this study are
followed. Fine scabbing and erythema resolved rapidly
and the condition and signs of general ageing of the skin
can be improved using the parameters described. Pulse
repetition rate with regard to the speed of delivery has
effects on thermal residual deposit in the dermis which
can be well correlated to better skin cosmetic outcome,
especially regarding the aspect of wrinkles, but with a
slightly longer recovery time.
It would be necessary for patients with degree III wrin-
kles, or those looking for more consistent results, to undergo
extra treatment sessions in order to improve the final out-
1111
laser pattern is noticed on the upper lip. (d) One month after treatment,
evident improvement of skin condition with practical disappearance of
pigmentation is observed
come. It is clear that greater thermal effects will give rise to
more setbacks for patients regarding the post-operative side
effects of resurfacing; however, fractional resurfacing as
practised here has not produced any complications. Various
treatment sessions will have the inconvenience of several
work-related absences, so every case should be carefully
evaluated before resurfacing is performed.
References
1. Trelles MA, Levy JL, Pardo L, Kontoes V, Soria C (2000)
Complication Du Relissage Laser CO2: Une Revue De 728 Patients.
Journal De Medicine Esthetique Et De Chirurgie Dermatologique
xxvii(107) – Issn 0249–6380:169–174
2. Gold MH (2007) Fractional technology: a review and technical
approaches. J Drugs Dermatol 6(8):849–852
1112
3. Trelles, MA (2008) Fractional CO2 laser clinical effects can be mon-
itored according to the need for skin aesthetic resurfacing. 17th
Congress of the European Academy of Dermatology and
Venereology (EADV), Paris, Abstract FP0752,
4. Trelles MA, Mordon S, Svaasand LO, Mellor TK, Rigau J, Garcia L
(1998) The origin and role of erythema after carbon dioxide laser
resurfacing. A clinical and histological study. Dermatol Surg
24(1):25–29
5. Trelles MA, Rigau J, Pardo L, Garcia-Solana L (1999) Electron
microscopy comparison of CO2 laser flash scanning and pulse tech-
nology one year after skin resurfacing. Int J Dermatol 38(1):58–64
M.A. Trelles
6. Trelles MA, Mordon S, Benitez V, Levy JL (2001) Er:Yag laser
resurfacing using combined ablation and coagulation modes.
Dermatol Surg 27(8):727–734
7. Trelles MA (2004) Laser ablative resurfacing for photorejuvenation
based on more than a decade’s experience and 1200 patients: per-
sonal observations. J Cosmet Dermatol 2:2–13
8. Trelles MA, Soria C, Pardo L, Chamorro JJ, Makaron T, Buezo O
(1998) Renovacion anatomica y estetica de los labios, con ayuda del
laser. Cir Plast Ibero Lat Am 24(1):63–71
 Laser Resurfacing
Franco R. Perego
1 Introduction
Carbon dioxide (CO2) laser was firstly used in the medical
field in 1964 and then becomes the most widely used laser in
dermatology.
The reasons why doctors used the CO2 laser were clear
from the very beginning, and they progressively gained pop-
ularity among most surgical specialties:
• A highly destructive power (either in cut and in ablation)
• But, at the same time, highly selective
• And as a consequence, highly conservative
In aesthetic surgery, the 1980s and 1990s are the 20 years
in which the dermatologist and the plastic surgeon had actu-
ally created, thanks to the lasers, a new and fascinating non-
invasive method of skin rejuvenation.
The CO2 laser produces an invisible beam of infrared light
with a wavelength of 10,600 nanometers (nm) that has a
good affinity for both intra- and extracellular water, with a
peak of absorption around 3,000 nm. When the luminous
energy is absorbed by tissues (water constitutes around 70 %
of the skin tissue volume), the phenomenon of “vaporiza-
tion” occurs. This is associated to an area of residual thermal
damage of decreasing entity depending on whether the pulse
is generated in continuous, pulsed, or superpulsed modality.
As regards the energy that is necessary in order to reach
the threshold of cutaneous vaporization, the laser system
needs to generate 5 J/cm2. In particular, the residual coagula-
tive necrosis is minimal when the time of tissue exposure is
less than 1 ms, i.e., inferior to the water thermal relaxation
time that is 800 μs.
The first CO2 lasers emitted in continuous modality for
more than 1 ms with areas of residual thermal damage around
F.R. Perego, MD
Scuola di specializzazione in Chirurgia Plastica,
Università di Padova, Padova, Italy
e-mail: info@arsmedicasrl.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_76
200/600 micron versus 25/70 micron of pulsed or continuous-
scan lasers.
Once these basic work parameters are created, it is always
possible with any device having such characteristics to reach
the main purpose of the laser resurfacing, i.e., a selective
photothermolysis [2], constituted by the fusion of its two
main constitutive elements [5]:
• Epidermolysis, i.e., the selective ablation of one or more
dermal layers, with a clinical outcome of skin rejuvenation
• Dermal heating, with subsequent fibroblastic stimulation
and neo-synthesis of collagen and elastin with a clinical
outcome of skin tonification, the so-called lifting effect
Laser resurfacing
Selective photothermolysis
Epidermolysis Dermal heating
(epidermal ablation or destruction) (neosynthesis og collagen) =
elastic retraction and
compactness
From the 1980s, the concept of surgical face rejuvenation,
which so far was intended as detachments and tractions,
underwent a revolution developing a new concept of exces-
sive skin repositioning instead of elimination. A ray of light
opportunely transformed in heat could make the aging skin
lighter and more smooth and compact as well as stimulate its
elastic retraction in order to solve the mild to moderate-
degree laxities and improve the severe ones.
Wrinkles, skin spots, post-acne, posttraumatic and surgi-
cal scars, skin lesions and defects of the skin surface, and
burn outcomes and cutaneous laxities [3] were the preferred
target of this new surgery [4] with a dramatic reduction of
bleeding, residual scars, and recovery time and with an
increasing demand from both doctors and patients.
Just like any other method, laser resurfacing treatments
showed a certain number of side effects and complications [6],
1113
1114
mainly erythema, edema, hyper- and hypopigmentation of the
skin, infection, and pathological scarring. As such, the industry
began studying new laser systems that were able to reduce the
residual thermal damage by removing the epidermal layers in a
progressive, controlled, and predictable manner.
Firstly, the characteristics of CO2 laser emission were
modified, thanks to a “shutter” system controlled by a com-
puter that was able to scan a ray emitted in continuous
modality so rapidly to limit the skin exposure time below
water thermal relaxation time.
Simultaneously, systems with different wavelength were
developed. In 1996, the erbium:YAG laser (2,940 nm) [6]
obtained the FDA approval for the skin resurfacing method
demonstrating an affinity for water 18 times higher than CO2
laser and a decisively inferior residual thermal damage.
During the last 10 years, ablative lasers have been flanked
by the so-called “non-ablative” lasers, which stimulate the
fibroblastic activity through an intradermal thermal insult
without epidermal ablation, and the “fractional” lasers [7],
with whom small areas of removed tissue are alternated to
areas of intact tissue in order to obtain a more rapid healing.
Currently, the most commonly used ablative laser systems
are the CO2 laser in pulsed and superpulsed modality, the frac-
tional CO2 and erbium:YAG lasers [8] and the more modern
multiwavelength, variable-pulse-width erbium:YAG lasers.
Some practitioners combine the different methods in
order to take advantage of the specific characteristics of each
one to obtain more complete clinical results with shorter
recovery time and lower incidence of side effects and
complications.
2 Cutaneous Histology
A precise knowledge of cutaneous histology allows us to
know the potentialities and limits of a laser resurfacing proce-
dure and to diagnose the level of the defect in order to choose
the best laser option as well as the appropriate parameters.
For this aim, I have created a three-level simplification of
the Rubin classification that correlates the degree of skin
damage and its histological localization (Table 1).
Then, I have correlated this classification with a similar
three-stage (white, brown, and dark) simplification of the
Table 1 Modified Rubin classification
Level Clinical signs
I Pigmentation abnormalities
II Marked pigmentation abnormalities; actinic or seborrheic
keratosis can be present; wrinkles
III All the abovementioned signs associated to deep wrinkles and
thickened skin
F.R. Perego
Fitzpatrick classification obtaining a simple level diagnos-
tic table (Table 2) that allows us to insert the characteris-
tics of the patient that we want to treat, giving us a practical
guide to reach the most complex target of this method: the
end point.
In practice, a fair-skinned patient with pigmentation
abnormalities and presence of non-deep wrinkles will be
inserted in our table as C-II, so that we are immediately
referred to the choice of parameters that allow us to treat
the epidermis and papillary dermis. In addition, with the
most recent laser devices, it is possible to dose with preci-
sion the depth of action of the laser beam, as such our work
can actually be considered safe and rarely affected by
undesirable clinical effects.
When the defect is limited to the superficial epidermal
layers (from 20 to 50 micron), it is sufficient to dose one pas-
sage of erbium laser with the same depth of action, while in
case of defects that extend to the whole epidermis and the
papillary dermis, multiple appropriately dosed passages are
necessary. Therefore, this is the answer to the question “what
is the ideal laser?”: the ideal laser is a “level-dependent”
laser, that is, the laser that reaches the necessary skin level
with the lower residual thermal damage.
Other expedients will be progressively introduced, also
according to the clinical experience developed, such as
the ability to reach the desired level with the lower num-
ber of passages (in view of the proven dependence rela-
tion between the number of passages and the entity of the
residual erythema) and the ability to adequately change
the length of the emitted pulse (as a short or very short
pulse has more ablative characteristics, while a long pulse
is followed by a marked stimulating action on the neo-
synthesis of collagen and elastin).
Table 2 Level diagnostic table
Rubin I Rubin II Rubin III
White WI W II W III
Brown BI B II B III
Dark DI D II D III
Histology
Alterations of the epidermis
Alterations of the epidermis and papillary dermis
Alterations of epidermis, papillary dermis, and reticular dermis
Laser Resurfacing
3 Techniques in Use
Numerous clinical and histological studies have been real-
ized with the aim of comparing the different laser systems
available and their respective parameters.
At the beginning the erbium lasers were mostly used for
the treatment of patients with moderate-degree skin laxity
and prevalence of “dyschromic aging.”
Wrinkles and skin laxity of higher degrees instead were
better addressed with CO2 lasers, even if they were a burden
with a higher number of postoperative complications and
longer recovery times.
The growing development of technologies has leveled the
differences between the two main laser systems, so that the
critical evaluation of the healing processes and side effects
resulting from the comparative use of a single-passage CO2
laser and a long-pulse multiple-passage erbium:YAG laser
did not reveal significant differences:
• The reepithelialization times were similar.
• Moderately longer (25 %) the duration of the erythema
with the use of a CO2 laser.
• Similar incidence of transient hyperpigmentation.
• Absent in both systems the onset of irreversible hypopig-
mentation and pathological scarring (hypertrophic and/or
keloid).
The development of the variable-pulse erbium:YAG has
created an important compromise between the two laser sys-
tems, both in terms of results and better tolerability of the
method. Also the lower coagulative capacity of the erbium
laser compared to the more hemostatic CO2 laser has pro-
gressively changed, thanks to the possibility to combine in
the same machine two types of pulse emission with erbium
laser: one short and with high fluence to realize an optimal
ablation and the other long but with lower potency to realize
a better control of the hemostasis [10].
In any case many surgeons prefer a combined CO2/erbium
approach in order to increase the collagen contraction in cer-
tain areas reducing the postoperative sequelae on other areas.
The variable geometrical design scanners are also widely
used. Usually two to three passages are performed, with flu-
ence between 2 and 5 J/cm2 (threshold of cutaneous abla-
tion): layer after layer, using gauzes or cotton pads
impregnated with sodium chloride, the vaporized tissue
should be completely removed at every passage in order to
limit the residual thermal damage and to observe with more
precision the skin color after each passage.
Also the effect of collagen contraction (superior to 25 %)
is visible with the naked eye and in a progressively increas-
ing manner as we get closer to the dermis.
Typically the residual defects are then treated isolately by
using small diameter spots without forgetting one of the
1115
basic parameters of the method: a reduction of the diameter
of the spot, with the potency being equal, inevitably leads to
an increase, sometimes dramatic, of the emitted fluence:
P ( potency ) ´ T ( time )
F ( fluence ) =
S
The operative behavior should always refer to a series of
maneuvers and cautionary measures used in every laser
resurfacing procedure:
• The face is accurately cleaned and disinfected with non-
inflammable solutions (chlorhexidine, Betadine).
• Special metallic (leaded) ocular protectors are positioned
after applying an ophthalmic ointment.
• The peripheral areas of the face and the neck should be
protected with wet clothes, and the hair coming out from
the clothes should be wet.
• In case a single cosmetic region is treated, the anesthesia
can be local or with locoregional blocks; in case of a pro-
cedure on the whole face, an intravenous sedation is per-
formed, which is realized with a mix of anesthetic agents
(propofol, midazolam, fentanyl, ketamine).
• The monitoring of the peripheral oximetry, blood pres-
sure, and ECG is always performed in case of sedation. A
reanimation kit with the possibility of intubation and defi-
brillation should be present in the operating room.
• In case a nasal cannula is used for oxygen perfusion, this
should be accurately isolated with a wet bandage, and the
anesthetist should interrupt the perfusion when the sur-
rounding areas are treated.
• A smoke aspirator is indispensable.
The healing starts from the migration of normal well-
organized cells deriving from the follicular annexes that
replace the atypical cells of the photodamaged skin, along
with the production of a new collagen matrix that is an addi-
tional stimulus to the immunitary factors from the fibroblasts
that migrate in the laser-induced wound.
During the reepithelialization process, which takes
7–10 days, the treated skin should be kept wet with soothing
creams and ointments in order to prevent the formation of a dry
scab that would impede the migration of the epidermal cells.
The dressing can be “open,” allowing the surgeon to
observe the evolution of the healing processes, or “closed,”
using a semi-occlusive medication. The latter is definitely
more comfortable for the patient that will experience a less
intense burning feeling during the first postoperative hours and
avoids undergoing all the medications that an open dressing
involves. But then, an occlusive dressing can be responsible of
a higher incidence of bacterial and mycotic infections.
For this reason, some practitioners use a closed dressing
during the first days, followed by an open dressing until the
complete healing.
1116
All the patients undergoing a procedure on the whole face
or the perioral region are given oral prophylactic antiviral
drugs, starting from the day before surgery and for the fol-
lowing 5 days.
The use of antibiotics is controversial because of the
potential development of resistant bacterial lineage and
always involves antibiotics against gram-positive bacteria,
which are statistically more frequently responsible of
infections.
Cortisone drugs are only prescribed for short periods and
in case of evident inflammatory reaction (large edema or
allergic reactions).
4 Author’s Favorite Technique
Those who had the chance to use the first laser resurfacing
systems at the beginning of the 1980s remember that the first
CO2 lasers used in continuous modality had as their only
defense a temporization of the pulse that reached the maxi-
mum reduction at 1/30 of second.
When the first laser systems in pulsed modality or with
scanned pulse (both with geometrical scanner and “brush”
technique) became available at the beginning of the 1990s,
we assisted to a real explosion of the laser method. I have
used the CO2 laser for several years with the brush technique,
as I considered it less subject to mathematic rules and more
adaptable in a “surgical” way. With that kind of scanner, it
was possible to manually vary the exposure times of the tis-
sues to the laser beam by slowing or fastening the passage of
the handle according to the treated region of the face. I
believe that it is indispensable to have the possibility to con-
trol the emitted energy in order to limit the entity of compli-
cations and postoperative sequelae (Fig. 1), without
renouncing obtaining good results (Fig. 2).
Fig. 1 CO2 laser resurfacing in the 1st, 4th, 8th, and 45th postoperative day
F.R. Perego
With the advent of the first erbium:YAG lasers, just like
many colleagues that had some experience with the CO2
laser, I considered the erbium a “minor” laser for superficial
defects or for patients that wish minor results in exchange for
rapid postoperative recovery. Basically, the erbium laser
missed then the fundamental requisite of the “dermal heat-
ing,” and most surgeons kept on using the CO2 laser.
It was totally by chance that I discovered an interesting
variation of the technique: after completing the classical two
or maximum three ablative passages with the CO2 scanner,
while I was finishing off with a single spot (1 mm) handle the
small residual defects, I noticed that the small point-like
spots, apart from removing tissue in a micrometric manner,
generated a series of dermal microcontractions that were
clearly visible with the naked eye and that, distributed on a
surface of several cm2, were able to create a pleasant tension
and tone of the treated area. The entity of the objectifiable
contraction was inversely proportional to the skin thickness,
and therefore its use was even more adapted for delicate
areas. I presented the method with the name of MST (Micro
Spot Technique) and started to use it in a systematic way in
all resurfacing treatments, both for the treatment of difficult
areas with thin skin (e.g., eyelids or orbitozygomatic region)
and for refining wrinkles and scars of different types.
The MST with CO2 laser can be used with any machine
and with a simple “single spot” handle both on previously
laser-treated skin (Fig. 3) and on intact skin (with the only
aim of creating a dermal heating), for example, after a trans-
conjunctival blepharoplasty (Fig. 4).
With the introduction of the variable-pulse erbium:YAG
laser, I started to use it systematically, especially associated
with the CO2/MST technique (Fig. 5), so as to increase the
shrinkage (contraction) effect of the collagen without pro-
longing the operative time.
However, it is with the most recent innovations of the
erbium laser [9] that I have further modified my personal
Laser Resurfacing
Fig. 2 CO2 laser resurfacing: pre- and 45th day postoperative aspect
technique: two 2,940 nm laser sources that work simultane-
ously in the same machine and that allow to (Fig. 6):
• Emit short pulses to vaporize the tissue in a traditional
way.
• Emit long pulses to create an area of dermal damage.
1117
• Select in a precise way the depth of ablation (from 0 to
200 micron) and/or coagulation (from 0 to 130 micron).
• Eliminate the need of having more laser platforms.
Also, with the same machine [1] I have another technical
variation, which I reserve to patients that wish a simple
1118 F.R. Perego

refreshing or a deep dermal stimulus with extremely reduced

recovery times (Fig. 7):

• In the first case I perform a “Micro Laser Peel” with the appli-
cation of topical anesthesia, with a depth that varies from 20
to 50 micron that allows a 3- to 4-day recovery time.
• In the second case I associate a fractional resurfacing with
variable depth up to 1,500 microns (1.5 mm) that, repeated
over time, reduces wrinkles and photo exposure damages,
renewing the superficial tissues without complications
and with an extremely reduced “downtime.”

5 Complications

It is important to remind that the laser determines a thermal

damage and de-epithelializes the skin, and as a consequence it
is normal to expect a series of side effects such as edema, ery-
thema, burning, or itching that should be differentiated from
the complications. Nevertheless, even in expert hands, it is pos-
sible that a series of moderate to severe complications occur. It
is therefore important to carefully follow the course of the heal-
ing process in order to precociously diagnose a problem and to
limit its evolution. It is frequent to observe irritative (contact) or
allergic dermatitis, formation of milia, acne reacutization, and
postinflammatory hyperpigmentations. Complications of mod-
Fig. 3 MST/CO2 on the orbitozygomatic region
erate degree include localized viral, bacterial, or mycotic infec-
tions as well as prolonged alterations of pigmentation and areas
with longer healing times [11, 12].
Most severe complications, which luckily are rare, involve
pathological scarring, ectropion, and disseminated
infections.
A delayed diagnosis can determine the formation of
keloids, permanent depigmentation, and skin necrosis.

Pearls and Pitfalls

Fig. 4 MST/CO2 on intact skin after transconjunctival superior and
inferior blepharoplasty
When a laser resurfacing treatment is performed for the
first time, prudence guides us to use conservative flu-
ences, proceeding gradually to the removal of epidermal
layers, until an evident contraction is seen, which identi-
fies the reaching of the desired dermal level. However,
this is not always the optimal procedure nor the safest,
Laser Resurfacing 1119

Fig. 5 Erbium:YAG laser + MST/CO2; from left to right: preoperative, 1st and 15th postoperative day

a b

Fig. 6 Variable-pulse erbium laser; (a) preoperative and 9th postoperative day; (b) 45th, 120th postoperative day

Fig. 7 Variable-pulse erbium laser; pre-, intra-, and 5th day postoperative aspect
1120 F.R. Perego

as for side effects and complications. First of all, we often
have a patient under local anesthesia or sedation; as such, a
useless prolonging of the operative time can compromise
the degree of patient’s tolerability, increasing our irritabil-
ity for his progressive complains and reducing our preci-
sion at work.
A good practice is to determine a precise overview of
the level of the defect (see level diagnostic table) in order
to selectively choose the starting parameters. Secondly, it
is useful to perform a first test on a “safe” area of the face
(the retroauricular region is perfect) by using an interme-
diate fluence and progressively increasing it until the
desired effect of ablation and an initial dermal contraction
are observed.
Once the ideal parameters for the patient are identified,
we can maintain them in the standard areas (forehead and
cheeks) in order to realize an effective and rapid epider-
molysis, whereas it is necessary to reduce the fluence and
number of passages on the so-called difficult areas and
lower thickness areas (eyelids and transitional areas of the
orbital region).
After realizing the second and in case the third pas-
sage, we should decide when to stop recognizing also
visually our “end point.” This is found by observing the
maximum level of dermal contraction and soon after
noticing a chromatic variation of the treated tissue that
changes from pink to yellow.
It is then important to avoid some pitfalls that often
occur in our surgical practice:
• When isolated areas of the face are treated, the entire
cosmetic unit should be treated.
• In case of association with an inferior blepharoplasty,
the dissection of a myocutaneous flap should be
preferred.
• In case of associated face lifting, the preauricular
region should not be treated (where the photoaging has
very little effect).
• Do not treat the canthal regions and the upper eyelid
tarsus.
• Do not treat the neck.
• Do not treat skin lesions without a previous biopsy.
• In case of “spots” remember two important
concepts:
– The end point should not necessarily be the elimi-
nation of the pigment, but avoid pushing the laser
beam at the level of the reticular dermis (as in case
of dermal melanosis).
– Use a long pulse, avoiding the typical short pulse,
often too aggressive on melanocytes and responsible
of unpredictable chromatic reactions.
Finally, rigorous criteria of patient selection should
always be carried out, especially for those patients with
unrealistic expectations or with an evident state of psy-
chological instability, giving them anyway precise infor-
mation about recovery times and modalities and about the
outcome, not only in qualitative terms but also in tempo-
ral terms.

Informed Consent

Surname and name…………………………………………………….date………………………..

With this consent I authorize Dr. …………………………………………………… and his co-workers to perform a pro-
grammed surgical procedure of Laser Resurfacing, whose nature, modality of execution and possible complications have
been extensively discussed during the pre-operative visit.
Today, with the aim of being formally informed about the possible risks of the surgical procedure that I wish to undergo, I
have been given this consent, which I will return completely filled-in the day of surgery.

Signature……………………………………

WHO IS THE CANDIDATE

The person that presents wrinkles and skin laxity of the face, irregularities of the skin surface due to the presence of post-acne
scars or scars of different nature and pigmentations of different kinds.
Men and women of every age can benefit from this procedure.
Laser Resurfacing 1121

DESIRED RESULTS
A smoother and more uniform skin.

DESCRIPTION OF THE PROCEDURE, RISKS AND COMPLICATIONS

There are several treatments of skin resurfacing, such as dermal abrasion and chemical peeling, which basically act in the
same way: firstly, the damaged skin layers are removed and then, with the formation of new cells during the healing pro-
cess, a more compact and uniform skin surface with a younger aspect appears.
The laser method allows to reach such target with several advantages: higher precision of action on the damaged skin layers,
absence or minimal presence of bleeding, better post-operative course.
The most commonly used laser is the Erbium Yag because it is more selective towards the skin: it emits a light beam that
heats and vaporizes the skin, reaching the damaged layers with elevated selectivity.
In cases of deeper wrinkles and major laxities it is often used, or associated, the CO2 laser.
In cases of initial skin aging both the Erbium laser and the so-called fractional modality CO2 laser can be used, which allow
a marked reduction of postoperative sequelae and recovery time.
In many cases wrinkles appear in localized areas (eye contour, mouth) and the laser can be specifically used on these regions.
However, there are skin conditions that impede the treatment of the whole face.
Patients with olive, tanned or dark skin are at risk for pigmentation abnormalities, as such an attentive evaluation and a spe-
cific skin preparation should be performed whenever you decide to undergo the procedure.
Patients that have assumed Accutane (isotretinoin) during the last 12 months or that are prone to pathological scarring (i.e.
keloids) or are affected by active herpetic eruptions are not good candidates for the procedure.
The procedure of “Laser Skin Resurfacing” can improve the aspect of the face reducing the wrinkles, but only the static ones,
while it cannot eliminate the dynamic wrinkles that depend on the mimical movements of the face and that require other
surgical procedures to be treated.
The procedure always requires an adequate skin preparation for at least three to four weeks and consists of the daily applica-
tion of specific products.
In case isolated areas of the face are treated local anesthesia is sufficient, while for the treatment of the entire face an intra-
venous sedation or general anesthesia will be added.
Pain is usually minimal and tolerable during the 24/48 hours after surgery.
Swelling is always present and its entity depends on both patient’s personal reactivity and depth of treatment, but it is usually
reversible during the first 7/15 days.
Usually the skin is decisively redden on the first 5/6 days to then become dark pink after the first week and a lighter pink after
the second week, until the reddening disappears within one or two months. In special cases and in delicate areas like the
eyelids the reddening can last longer and require special treatments in order to fasten the process of normalization of the
erythema.
From the seventh day on usually most patients can apply a specific covering make-up.
It is very important during the following three months to avoid sun exposure until the whole skin color is back to its normal
aspect and to use a total block sun protection in any case.
In case periocular regions have been treated it is advisable to wear good quality sunglasses with 100% UVA-UVB filters.
The achievement of an optimal aesthetic outcome can require several months, which are necessary for the production of col-
lagen, however, when the reddening fades away the patient is already able to notice an evident improvement of skin
quality.
Despite the high degree of precision of the laser, not all the wrinkles or skin irregularities can be solved with one treatment
and in many cases several treatments are needed in order to reach the desired results.
It is important to know that the obtained result is not permanent because the new skin will not be unaffected by the aging
processes.
After a laser resurfacing treatment there is the possibility of developing abnormal skin pigmentation with the presence of
spots and areas of hyperpigmentation: these are usually transient alterations that can be resolved in weeks or months,
provided that it is treated with specific products and procedures and with the avoidance of sun and UV rays exposure.
There is also the possibility of delayed skin healing processes, with the presence of pathological scars and areas of irrevers-
ible hypopigmentation, usually due to an excessive depth of treatment.
I give consent to be photographed before, during and after surgery with the aim of clinical documentation and possible sci-
entific use.
1122 F.R. Perego

Believing of having received clear and precise information on every detail of the surgical procedure I wish to undergo, I
undersigned:

Surname………….Name……………………………………
Born on …..in……………………………………………….
Authorize Dr. ……………………………………………….
And his co-workers to perform the surgical procedure of:…
Under anesthesia…………in date…………………………..
Place……………………………………………………….
I also authorize Dr. (surgeon) ………………………………
And Dr. (anesthesist)……………………………………
And their co-workers to modify according to their knowledge and judgment and according to the contingent needs the
surgical and anesthesiological programmed techniques, both during surgery and in the post-operative period.

Date…………………………………………………….
Patient’s signature…………………………………………
(or legally authorized representative)

Surgeon’s signature………………………………………..

References 7. Rokhsar CK, Fitzpatrick RE (2005) The treatment of melasma with

fractional resurfacing: a pilot study. Dermatol Surg 31(12):
1645–1650
1. Patel CKN (1964) Continuous wave laser action on vibrational
8. Pozner JN, Goldberg DJ (2006) Superficial erbium:YAG laser
rotational transitions of CO2. Phys Rev 136(5A):A1187–A1193
resurfacing of photodamaged skin. J Cosmet Laser Ther 8(2):
2. Goldman MP, Fitzpatrick RE (2003) Cutaneous laser surgery: the
89–91
art and science of selective photothermolysis. Eur J Plast Surg
9. Whoo SH, Park JH, Soo NK (2004) Resurfacing of different types
25:439
of facial acne scar with short-pulsed, variable-pulsed and dual
3. Fitzpatrick RE, Goldman MP (1993) Advances in cutaneous laser
mode ER:YAG laser. Dermatol Surg 30(4 Pt 1):488–493
surgery. West J Med 159(4):509–510
10. Rostan EF, Goldman MP, Fitzpatrick RE (2001) Laser resurfacing
4. Stevenson TR (1993) Laser treatment of skin lesions, important
with a long pulse erbium:YAG laser compared to the 950 ms pulsed
advances in clinical medicine-plastic surgery. West J Med 158:404
CO(2) laser. Lasers Surg Med 29(2):136–141
5. Anderson RR, Parrish JA (1983) Selective photothermolysis: pre-
11. Anderson RR, Azpiazu JL et al (2006) Complications of laser der-
cise microsurgery by selective absorption of pulsed radiations.
matologic surgery. Lasers Surg Med 38(1):1–15
Science 220:524–527
12. Manuskiatti W, Fitzpatrick RE, Goldman MP (1999) Long-term
6. Alster TS, Lupton JR (2000) Treatment of complications of laser
effectiveness and side effects of carbon dioxide laser resurfacing for
skin resurfacing. Arch Facial Plast Surg 2:279–284
photoaged facial skin. J Am Acad Dermatol 40(3):401–411
 Intense Pulsed Light Systems
M.G. Onesti and P. Fioramonti
1 Introduction
Intense pulsed light (IPL) systems are incoherent and have high
irradiance light systems. Despite not being considered as part
of the laser family (given the non-collimated and non-coherent
nature of their emission) they have proved their efficacy in
interacting with tissues and are still subject to careful and
objective evaluation. IPL systems, at first, were poorly consid-
ered because of their nonspecific characteristics [7, 30, 33].
In 1990, Goldman and Eckhouse began to develop new
high-energy lamps to treat skin vascular anomalies [15–16].
The first IPL system-based device became operative in 1994
(PhotoDerm1 VL, Lumenis Ltd., Yokneam, Israel). Over the
years a number of innovations followed, which allowed to
widen the range of possible indications. Today, it is basically
used for facial rejuvenation (spots), for vascular lesions, and for
epilation, but new potential indications are being successfully
experimented (e.g., melasma, infective phase acne, stretch
marks, iatrogenic erythema, etc.) [14, 17–18, 29, 34, 38].
IPL systems emit light with a wavelength between 400
and 1,200 nm. Various manufacturers offer different filters
(400, 515, 550, 570, 590, 615, 695 and 755 nm) which allow
to exclude shorter wavelengths and obtain the proper ones to
interact with the selected target. The wavelength can be mod-
ulated according to the depth of the targeted tissue; longer
waves consent a deeper penetration into the dermis [41].
The pulse length of the IPL source can vary between 0.5
and 88.5 ms. Energy can be conveyed into a single pulse or
multiple pulses with delay times of 1–500 ms.
These intervals, called thermal relaxation time (TRT),
allow epidermis to cool, thus avoiding the risk for unwanted
M.G. Onesti, MD (*)
Dipartimento di Chirurgia, Università di Roma
“Sapienza”, Policlinico Umberto I, Rome, Italy
e-mail: mariagiuseppina.onesti@uniroma1.it
P. Fioramonti, MD
U.O.C. di Chirurgia Plastica e Ricostruttiva, Università di Roma
“Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_77
heat accumulation. A chilled gel is used during treatment,
additional external cooling systems make possible to use
higher power reducing risks for the skin.
The exploitable fluence varies from 3 to 90 J/cm2. The
spot, which corresponds to the size of the crystal in contact
with the skin, usually of a rectangular shape, is 10–50 mm
long.
Being monochromatic is the winning feature of laser,
while IPL distinguishing characteristic is its possibility to
treat simultaneously the specific absorption peaks of the
three main chromophores (hemoglobin, water, and melanin).
However, this feature requires a careful evaluation of the
patient’s characteristics and of the lesion to be treated in
order to avoid complications and adverse effects.
Moreover, while true laser systems allow limited change of
parameters (only power and spot size), IPL systems consent
further changes (length and number of pulses, delay between
pulses), which are essential to achieve optimal results.
A future better knowledge of IPL’s possible uses will
surely permit the treatment of pathologies today considered
as unsuited to light source treatment.
2 Treatment
The technical phases of the treatment are identical for all
indications. Of course, parameters used vary depending on
whether performing skin rejuvenation, epilation, or vascular
lesion treatment.
Treatments must be preceded, at the time of first examina-
tion, by a clear exposition of the method, the expectable out-
come, and possible complications. A written consent form
will be presented, to be read by the patient and possibly
explained and discussed before being signed. It is always
advisable to take photos to document the pretreatment
situation.
To undergo an IPL session the patients must not have
active dermatological illnesses (herpes, skin infections) and
must not be suntanned or wear makeup. After a careful
1123
1124 M.G. Onesti and P. Fioramonti

evaluation of the phototype, which is necessary because IPL the appearance of freckles to skin spots even to melanosis
treatment, even more than laser, may not be suited to patients and vascular abnormalities such as telangiectasias and ery-
with a dark skin. A test spot will be done in an inconspicuous thema, associated or not with rosacea may appear (Figs. 1
area to evaluate the adequate power and even more the and 2) [21]. It is to be underlined the frequent appearance of
patient’s skin reaction. skin keratoses, dyskeratoses, and even true cancerous lesions
The face is then disinfected with nonalcoholic substances, (basal and squamous cell epithelioma, melanoma) [19].
a chilled gel is applied, and the handpiece is positioned so as Such complications are more frequent in subjects with a
to maintain contact with the skin for the whole treatment. light skin phototype, who are luckily the best candidates for
Usually, it is not necessary to use local anesthetics. Applying IPL treatment [27]. Of course, treatment must necessarily
anesthetic creams 20 min in advance may be useful with be preceded by dermatological examination in order to
hypersensitive patients. exclude the presence of neoplastic disease.
The size and the maneuverability of the handpiece are of
crucial importance in the facial treatment, especially on
irregular surfaces, like the nose dorsum or the upper lip. It is
imperative to remember the need to protect eyes and tissues
which may interact with IPL (vermilion, hair bulbs, nevi, and
tattoos).
Commonly, one pass is sufficient to treat the selected
area; however, if required, it is possible to deliver more
passes with a different orientation of the handpiece.
At the end of the treatment, an erythematous reaction
develops, which lasts 2–48 h. To minimize this reaction, zinc
oxide ointments are generally used right after or in the fol-
lowing hours [37].
More sessions are usually necessary according to the
pathology to treat, at intervals of 3–4 weeks. Fig. 1 IPL pre-treatment (note melanosis)

3 Facial Rejuvenation

Within the ever-increasing demand for noninvasive yet effec-

tive methods for facial rejuvenation, IPL technology
launched in 2000 appears as the nonsurgical alternative to
lifting and to ablative lasers. The great flexibility of this tech-
nique allows simultaneous intervention on all the marks of
photoaging [1, 11–13] (Fig. 1).
This pathology is due to the combined action of two groups
of concomitant factors: intrinsic ones (age, genetic disposition,
phototype, etc.) (Table 1) and extrinsic ones (uncontrolled
exposure to solar radiations, smoking, lifestyle, etc [24]).
Classically, a photo-damaged skin shows alterations in
skin texture, mainly depletion of the dermis and dehydra-
tion. In addiction changes in pigmentation, varying from Fig. 2 Post treatment

Table 1 Fitzpatrick classification of skin type

Skin type Skin color Eye color Hair color Reaction to sun
I Light Blue green Red Burns, never tans
II Light Blue Blonde Burns, may tan
III Medium Brown Brown Burns, then tans
IV Moderate brown Brown black Brown black Tans
V Dark brown (Asian) Dark Black Tans
VI Black (African) Dark Black tans
Intense Pulsed Light Systems
Fig. 3 Pre-treatment (note large melanosis)
Fig. 4 Post treatment
3.1 Personal Technique
According to the patient’s characteristics, treatment is per-
formed with energy at 30–50 J/cm2 with double or triple
pulses of 2.4–4.7 ms, spaced 10–60 ms. The handpieces
commonly used are the 570 and 590 nm ones. Treatment is
normally delivered on the whole face to obtain a uniform
result. In case of a restricted localization of spots or telangi-
ectasias, treatment can be performed while observing the
single aesthetic unit (Figs. 3, 4, 5 and 6). Application of a
chilled gel will make the procedure totally painless. After the
reaction to the test spot, usually performed in the preauricu-
lar area, only one pass is used, keeping the handpiece always
at the same distance and with the same orientation, with
spots overlapping not more than 5 %.
1125
Fig. 5 Pre-treatment (note multiple melanoses)
Fig. 6 Post treatment
In some cases, a second pass can be done changing the
handpiece orientation. Normally treatment is followed by the
appearance of a diffuse erythema and a gradual darkening of
hyperpigmentations, which may increase in the next days, to
resolve spontaneously in exfoliation of the area. Applying
soothing creams soon after treatment and in the next 2 days
will reduce redness and allow a quick return to social life.
Sessions are repeated 4–6 times, every 3 weeks.
4 Vascular Anomalies and Pathologies
Vascular anomalies and pathologies (flat angiomas, telangi-
ectasias, rosacea, etc.) have been successfully treated over
many years using laser technology, which allows selective
treatment of vascular lesions using hemoglobin (oxidized or
reduced) as target [31].
Angiomas (also called hemangiomas) are neoplasms
mainly constituted by highly irregular interlacing of vascular
structures [25]. Angiomas are basically classified depending
on the content and depth of the blood vessels. According to
1126 M.G. Onesti and P. Fioramonti

the various aesthetic aspects they present, they are called flat
(known as port-wine stains), tuberous (because of their
bulge), subcutaneous or cavernous, mixed (tuberous and
subcutaneous), and stellar angiomas. The different evolution
of these lesions must be taken into consideration, as some
cases, after a first swelling, tend to regress spontaneously,
while others tend to a progressive thickening with the emer-
gence of intralesional nodules [32].
Telangiectasias or dilated capillaries are small blood
vessels of 0.1–1 mm in diameter. They are more frequent
on the face, often located on the cheeks and on the nose
wings. When originating from the arterioles of a capillary, Fig. 7 Front area erythrosis: pretreatment photo
they are small and of a bright red color; when originating
from the venules, they tend to be bluish and wide.
According to their aspect, they are classed into 4 main
types: simple or linear, arborized, spider and punctiform,
or papular.
Erythrosis is defined as a permanent and lasting condition
of redness and erythema. It is often connected to couperose
and rosacea, of which is a consequence.
Rosacea is a quite common dermathosis tending to
chronicize and locate in the central portion of the face.
Clinically, it has various evolutive phases, but it gener-
ally tends to worsen if left untreated. Rarely, it is present
just for a few months and regresses spontaneously; more
often it evolves into an intense congestion of the tissues Fig. 8 Results after five sessions
and has a chronic evolutionary course. Initially it appears
with a sudden and typical redness (flushing) in the central
face, which can be produced by a trivial temperature swing advantages due to greater speed in delivering treatment,
because of weather change or an emotional shock. The first lowering of possible scarring risks, and, most of all, reduced
lesions clinically noted are small expansions of superficial appearance of posttreatment purpura on exposed areas.
venular capillaries on the zygomatic regions, which tend to Therefore, it has made possible to treat successfully some
increase in number and dimension until creating a persistent widespread pathologies, such as erythrosis (Figs. 7 and 8)
erythema. Afterward, this condition of chronic erythrosis or poikiloderma of Civatte.
causes a thickening of the epidermis and even the appear-
ance of nodules. Etiology is still unknown up to this day,
even if the importance of familiarity, hormones, occupation, 4.1 Personal Technique
and lifestyles is recognized.
Poikiloderma of Civatte is, instead, a chronic disease Two filters are normally used. For telangiectasias and thin-
due to prolonged exposures to sunlight and characterized ner lesions, the 550 nm filter can be used, double pulse of
by tiny dilated capillaries on the face and décolleté, which 2.8–4.5 ms, with a delay of about 30 ms and energy at
give the skin a typical streaked appearance. Over the years, 38–42 J/cm2. Bigger lesions can be treated with 590 nm fil-
small multiple stains of a light brown color, appear next to ters, double pulse of 2.4–3.5 ms with delays of 25–30 ms,
the dilated capillaries. The skin under the chin is always and energy at up to 50 J/cm2 (Figs. 9 and 10). As for angio-
spared. mas, mostly of tuberous type, the patient’s hypersensitivity
Over the last few decades, the wavelengths that made must be taken into consideration during treatment and the
possible the laser treatment of these pathologies have var- more frequent appearance of purpura. As for the treatment
ied, depending on the two peaks of hemoglobin absorption, of erythrosis and of poikiloderma of Civatte, the filter used
from 500 to 690 nm for purple lesions (argon, dye laser, is of 560 nm; the pulse can be double or triple, spaced
KTP, copper vapors) until 1,064 for bluish lesions 20–40 ms. Energy can vary from 9 to 12 J/cm2 according to
(neodymium:Yag). The good results achievable had as a phototype.
side effect possible bluish stains or small crusts, which It is important to inform male patients that treatment of
made difficult to accept the treatment for facial or more the buccal regions, site of vascular lesions, can produce a
extended lesions. Pulsed light has undoubtedly some temporary reduction of beard hair.
Intense Pulsed Light Systems
Fig. 9 Rosacea on central face: pretreatment photo
Fig. 10 Results after four treatments
5 Epilation
Still today epilation is a difficult challenge. The idea of
“excessive hair” is a relative one, and the standard is estab-
lished according to ethnic backgrounds, age, sex, and even
fashion, which often sets the trend to be followed. Various
laser types and IPL are used today to remove hair [8]. All of
them hip melanin as the targeted chromophore inside the hair
bulb (Table 2).
Good candidates for the treatment are both patients with
normal and/or increased hair with respect to site, and patients
with hypertrichosis and hirsutism. Hypertrichoses can be
classed as primary and secondary. The first depend on a
genetic predisposition; they are therefore congenital or appear
during childhood. Secondary hypertrichoses develop at a later
stage and are temporary: they are consequent to an external
stimulus to the adnexa (neoplasms, hormone or metabolic
disorders). Hirsutism is the appearance of hair in androgen-
1127
Table 2 List of lasers and IPL used in epilation and their wavelength
Ruby 694 nm
Alexandrite 755 nm
Pulsed diodes 800 nm
Nd:YAG 1,064 nm
Intense pulsed light 590–695 nm
Table 3 Depth of hair bulb according to anatomical area
Area Depth of hair bulb (mm)
Scalp 3
Face 1.5
Upper lip 1.5
Limbs 2
Trunk 2
Pubis 3.5
sensitive areas of a woman: this increase may mean an
increase in growth or the transformation of fuzz into terminal
hair [36].
An essential point when speaking of epilation is to distin-
guish between final and permanent. The exact definition is
still a question of debate. Final epilation means a total loss of
hair in the area under treatment, but it is an unachievable
goal. More practically, Dierickx suggests to call it permanent
when there is a meaningful decrease in the number of hair,
after a set number of treatments, which is stable over a period
of time longer than the full cycle of the hair follicle in the
treated area [5–6]. Olsen suggested to consider a longer
period adding 6 months to Dierickx’s estimation. Patients
can consider a treatment permanent when its effects last for
their whole life. For that reason, the informative talk during
the first visit is extremely important.
The treatment timing is fundamental. Despite the varia-
tions in length, growth phases, and type, all hair has a cyclic
growth. There are three phases: growth until the maximum
length is called anagen, then there is a more or less prolonged
phase of stability called catagen, and the final one of elimina-
tion is called telogen.
During the anagen phase, in the lower part of the bulb,
melanocytes transfer melanin to a mass of undifferentiated
epithelial cells (hair matrix), which form the different cellular
layers constituting both the hair root and the sheath. The ana-
gen phase varies according to age, sex, seasons, the anatomi-
cal area, the hormone levels, and the genetic predisposition.
While the anagen phase progresses, the bulb and the papilla
deepen into the dermis so that in the end hair becomes treat-
ment resistant. This is why follicle is more sensitive to damage
just at the beginning of the anagen phase. During the telogen
phase, the bulb has no pigmentation, and its production stops
during the catagen phase. It is generally recognized that pauses
between treatments are influenced by the anatomical area.
Due to the depth of the hair growth center, meaningful ener-
gies need to be used to obtain results (Table 3). Both destroying
1128
every single follicle and protecting the surrounding tissues,
especially the epidermis, are extremely important to avoid
drawbacks, which may sometimes be permanent.
The idea of using a laser source was first described by
Kuriloff in 1988. Argon laser was used in epilation to treat
trichiasis and Nd:YAG laser in epilation of grafts in the
urethra [20–26]. Dover first used successfully ruby laser to
damage pigmented hair bulbs, later also used successfully
by Grossman. Zaias suggested using a pulsed laser in epi-
lation in 1991 [40].
In 1997 Raulin published the first study on IPL use in epila-
tion and reported long-term hair removal on two transsexual
patients [28]. Biopsies showed atrophy of whole follicles with-
out any scarring on the skin surface. In 1997 Gold published a
study on a significant number of patients treated with one ses-
sion of IPL, using 590, 615, 645, and 695 nm filters, fluence at
34–55 J/cm2, with sequences of two to five strikes and delays
of 20–50 ms. Results showed a gradual improvement from the
fourth to the sixth weeks after treatment, while no meaningful
changes were observed from the fourth to the eighth week.
About 60 % of patients showed an epilation of 50–100 % [10].
In 1999, Weiss enrolled 23 patients with Fitzpatrick I–III skin
types who underwent only one treatment and 48 patients with
Fitzpatrick I–V skin types who underwent a double treatment
(at 1 month interval). Results showed greater effectiveness with
the second protocol, achieving a 64 % immediate posttreatment
removal [39]. In 2000, Bjerring proved the effectiveness of
delivering more treatments [2], and Sadick achieved a 76 %
epilation using 3.7 treatments on each patient [35].
5.1 Personal Technique
Careful study of the patient is essential before starting any
treatment. Parameters to be evaluated are skin color and
color and quantity of hair. A 625 nm filter is generally used
Fig. 11 Test spot in epilation
after 3 weeks (arrows):
assessment of results and local
effects
M.G. Onesti and P. Fioramonti
for standard epilation (skin type 1–4) and a 650 nm filter for
darker phototype patients.
A careful anamnesis needs to be done to establish the
possible origin of hypertrichosis and with the presence of
herpes simplex or genitalis the tendency to develop keloids
or hypertrophic scarring. Possible previous treatments under-
gone by the patient and assumption of medicines need to be
investigated.
All patients who suffered trauma or surgery within a
month and underwent electrolysis or infiltration of exoge-
nous substances are to be excluded.
Finally the patient’s expectations must be carefully evalu-
ated, underlying the limits of the technique and explaining
the possible side effects, which are then stated in the informed
consent form, to be signed by the patient at least 24 h before
the treatment.
Over the days before the treatment, photoexposure and
consequent tanning must be avoided, and bleaching prepara-
tions could be used especially with patients presenting a high
phototype; mechanic epilation and electrolysis need to be
avoided. It is always necessary to define the area to be treated
before carefully shaving it. Always use cooling systems and
local anesthetics for hypersensitive patients.
During the first examination, it is advisable to do a test
spot on an inconspicuous area of the face or the body with
different parameters (Fig. 11). In this way two results are
achieved: we assess the best values to treat the patient’s hair,
and we check a possible excessive reaction of the skin to
treatment generating side effects. Normally 4–8 sessions are
needed spaced 1 month apart (Fig. 12, 13, 14 and 15). More
recently, given the connection between the effectiveness of
the treatment and the initial anagen phase, it is preferred to
repeat sessions at the time of hair regrowth, which may hap-
pen after several weeks. Parameters are closely connected to
what mentioned above (phototype, hair density, area to treat,
device used).
Intense Pulsed Light Systems
Fig. 12 Hypertrichosis in mandibular area: pretreatment photo
Fig. 13 Results after five sessions
6 Complications
As in all aesthetic treatments, IPL use also needs careful
evaluation of side effects. These can be temporary, such as
erythema, vesicles, and crusts, or permanent such as scar-
ring, hypopigmentation, and hyperpigmentation. To reduce
these side effects always use a cooling system and careful
1129
Fig. 14 Hypertrichosis on underchin area: pretreatment photo
Fig. 15 Results after four sessions
shaving of the area needs to be done in epilation. This is
done to avoid unwanted heat accumulation in epidermis and
subsequent little burnings. The most severe complications,
like permanent dyschromia, are very often caused by a
faulty assessment of phototype or of the hair density on the
area to be treated, which brings to an unwanted heat accu-
mulation [9].
1130 M.G. Onesti and P. Fioramonti
Intense Pulsed Light Systems 1131

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Lasers Surg Med 12(Suppl):17
 Lasers and Intense Light Systems
as Adjunctive Techniques in Functional
and Aesthetic Surgery
Mario A. Trelles
1 Introduction
Aging is a natural event which is particularly noticed in
facial skin. A combination of a gradual loss of youthful tis-
sue integrity and the force of gravity produces a condition
which is difficult to reverse [1]. Chronological aging is addi-
tionally worsened by aggressive sunlight, which changes
biological tissue architecture and skin texture, attributable to
exposure to short, blue A and B ultraviolet radiation wave-
lengths [2]. The above factors accelerate the loss of the skin’s
structural condition [3]. Among the methods, protocols, and
apparatus aimed at correcting facial aging, to complement
the basic techniques of aesthetic surgery and to improve suc-
cessful results, simple procedures carried out with lasers can
help to remodel or rejuvenate the signs of aged skin [4].
Chemical peels, mechanical dermabrasion systems, and
lasers are designed to therapeutically cause a layer of dam-
age in dermal tissue, which upon repair leads to a wound
healing process that brings about restoration of youthful
characteristics of the treated skin [5]. In particular, collagen
deposition and subsequent remodeling with tightening and
shrinkage which are transferred to the overlying epidermis
are the treatment objectives.
When the skin itself is the aesthetic problem, as, for
example, accompanied by pigment disorders, scarring,
stretch marks, or redundant tissue with loss of elasticity, a
combination of phototherapy and surgery can recover the
subject’s youthful appearance. In the case of lax skin of the
upper or lower eyelids, this can lead to dermatochalasis or to
lateral canthal tendon laxity, respectively [6]. For other prob-
lems, such as scleral show, ectropion, or watering eyes with
signs of epiphora, the CO2 laser offers surgeons significant
help in their work to correct such circumstances [7].
M.A. Trelles, MD
Department of Plastic-Aesthetic Surgery and Lasers Section,
Instituto Médico Vilafortuny, Antoni De Gimbernat Foundation,
Cambrils, Spain
e-mail: imv@laser-spain.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_78
Lasers, as a surgical tool or as adjunctive treatment in
selected aesthetic surgical procedures, offer the possibility of
enhancing conventional aesthetic results. The following indi-
cations, in our experience, specify where laser treatment can
complement surgical aesthetics: (1) scar revision; (2) laser
techniques in aesthetic and functional eyelid and eyebrow
surgery; (3) treatments to improve skin condition, as in the
case of stretch marks; (4) fractional laser resurfacing com-
bined with chemicals for the treatment of troublesome facial
skin pigmentary disorders; (5) laser cartilage reshaping as an
alternative to surgical otoplasty; (6) breast reduction with the
aid of the Er:YAG laser in the deepithelization stage; and (7)
other applications such as nasal reshaping, lip functional res-
toration, and rejuvenation combining minor surgical proce-
dures such as fillers.
2 Scar Revision Using the Co2 Laser
Various treatment modalities have been proposed to improve
scarred tissue. Pulsed CO2 lasers can improve tissue condi-
tion with few side effects. Although the epidermis and der-
mis are involved in the treatment and results can produce
adverse effects such as erythema and pigmentary complica-
tions, fibrotic tissue is removed with efficacy and practically
no down time.
The dramatic improvement in the results obtained using
the CO2 laser during tissue resurfacing can be enhanced with
sessions of intense pulsed light (IPL) devices, LED therapy,
and fillers, if scars are depressed (Fig. 1).
Scars vary in depth, width, and color. If the CO2 laser is
used as a pulsed laser, fibrotic tissue can be eliminated with
well-controlled residual thermal damage (RTD). The CO2
laser positively remodels collagen, and this action is related
to RTD depth [8, 9]. The short pulse duration of the pulsed
CO2 laser produces a shallow depth of RTD [10]. Regenerated
skin obtains improved characteristics, quite similar to those
of normal tissue. Reepithelization can be activated with ses-
sions of LED therapy which not only speed up and modulate
1133
1134 M.A. Trelles

Fig. 1 Forty-four-year-old male,

a b
Fitzpatrick phototype III. (a)
Presents with extensive depressed
scar on left cheek, nose, and chin
produced accidentally. Lesion
shows tissue atrophy and hyper-
trophic lumping on the nose. (b)
Two CO2 laser sessions were car-
ried out for scar revision, together
with LED therapy to help skin
recovery

healing of the treated area but can enhance cosmetic charac-

teristics [11]. Scar revision is carried out with the UltraPulse
CO2 laser (Lumenis, Yokneam, Israel) with a 1 mm spot size,
7 W power, and pulses of 350 μs. Delay time between pulses
is set at 200 ms to avoid thermal accumulation. The laser
beam starts vaporizing the elevated portions of the scar from
the center to the periphery. Once the process of smoothing
the scar to the level of the surrounding healthy skin is accom-
plished, the remaining debris following laser treatment is left
in place. A fine layer of ointment, to help epithelization,
based on retinyl palmitate, DL-methionine, and gentamicin
(Novartis Farmacéutica, S.A., Barcelona, Spain), is applied
several times a day until the scabs fall off (Fig. 2).
Usually, various sessions are required to obtain a signifi-
cant improvement. In between CO2 laser sessions, and also
during the time tissue undergoes the process of reepitheliza-
tion, the area is subjected to LED light therapy sessions. We
normally administer the first session of LED therapy imme-
diately after CO2 laser surgery followed by a total of six
sessions, two per week, combining 633 and 830 nm quasi-
monochromatic wavelengths alternatively, directly on the
treated scar [12]. Moisturizers and sunblocks are then rec-
ommended as a cosmeceutical maintenance treatment. Once
the lesion has healed, if erythema is excessively evident,
phototherapy with IPL can be implemented. In fact, ery-
thema is related to active neovascular formation and an
immature epidermis formed by only a few cell layers in the Fig. 2 Typical aspect of the facial skin 48 h after CO2 laser fractional
treated area. Therefore, time is needed and patients should resurfacing. Notice the epithelium debris left in place to serve as a “nat-
be conscious of this. However, IPL sessions with the 585 nm ural dressing”
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1135

wavelength reduce skin redness by coagulating microves-
sels. Treatment of scar tissue is completed by recommend-
ing the use of pressure therapy with silicone patches for a
period of 1 month, 24 h a day, and then only at night for a
further 2 months.
3 Laser Techniques in Aesthetic
and Functional Eyelid and Eyebrow
Surgery
3.1 Correction of the Lax Lower Eyelid
3.1.1 Lateral Canthal Tendon Suspension:
Canthopexy
Partial or total scleral show and/or aptotic lower eyelid is
often accompanied by watering eye. The degree of skin lax-
ity is determined by the so-called snap test. With the patient
looking straight ahead, the lid is taken between the thumb
and the index finger, pulling the skin down and maintaining
a grip for 5 s. When released, the skin should return to its
normal position instantly. It is considered a lax eyelid if the
recovery time exceeds 5 s (Fig. 3).
Correction of lower eyelid laxity and the exposed sclera
using lateral canthal tendon suspension and orbicular muscle
repositioning with the aid of the CO2 laser has many advan-
tages [13]. Surgery is performed under local anesthesia,
administering lidocaine with a vasoconstrictor (1:2,000,000
epinephrine). Then the CO2 laser is used (UltraPulse®
Encore FX™, Lumenis™, Israel), set for incision mode in
continuous wave (CW), for a 7 W output, using the 0.2 mm
spot size handpiece. The lid is cut one millimeter below the
eyelash line. The laser incision, made laterally, follows the
classic cold steel surgical approach but with the advantage of
the bloodless surgery that the CO2 laser renders [14]. Incision
starts at the medial point of the lid and is extended externally,
approximately one cm off of the lateral canthus. The external
line of the incision should follow the central crow’s foot
wrinkle. A clean, blood-free dissection is performed to locate
the lateral canthal tendon, close to the projection of the
orbicular muscle, which is partially plicated to pull the sag-
ging eyelid causing a lateral tension. To achieve stable sus-
pension, a higher anchorage point is recommended in the
lateral orbital rim. One single stitch is often enough with a
5-0 nylon suture. In the case of redundant skin, elimination is
carried out with the CO2 laser until normal eyelid cosmetic
appearance is obtained.
Prominent fat bags often reinforce eyelid heaviness caus-
ing skin to protrude to the front, giving a visible anti-aesthetic
condition, increasing the sagging skin appearance. In these
circumstances, the lid is pulled down revolving externally,
hiding the gray line and making the conjunctiva visible with
scleral exposure (Fig. 4).
In such cases, lower lid fat bags should be eliminated by
extending the skin incision to the internal canthus. Then, the
Fig. 4 Fifty-eight-year-old male with very evident lower eyelid fat
bags showing the compartments of the middle, central, and lateral bags.
In such cases, transconjunctival blepharoplasty without taking into
account the skin lax condition could be a source of complications.
Surgery must re-shape flaccid skin; otherwise, it could worsen once fat
is eliminated and could lead to sclera exposure with mild ectropion

a b

Fig. 3 (a) Snap test to check

lower eyelid skin tension and
laxness of the lateral canthal
tendon. (b) Pinch test to check
the degree of cutaneous flaccidity
1136
a b
Fig. 5 Sixty-eight-year-old male Fitzpatrick, phototype II. (a) Prior to
treatment: redundant skin in upper eyelids and prominent bags in lower
eyelids. (b) Result of upper blepharoplasty with the aid of the CO2 laser
and elimination of lower eyelid fat bags transconjunctivally. Upper
septum is opened, and excision of the medial, central, and
lateral fat bags is done cleanly with the CO2 laser in CW at
7 W. By defocusing, and consequently enlarging the beam
size, the laser power per unit of area decreases, facilitating
careful and precise dissection of fat bags in a blood-free
field, thanks to the laser energy coagulation effect. The CO2
laser permits easy identification of anatomical structures
facilitating the whole surgical procedure. To finish off, a few
stitches are placed to suture the orbital septum, followed by
closure of the skin intradermally all using Vicryl ™6-0 mate-
rial (Fig. 5).
In the case of a wrinkled, lax lid presenting with evident
signs of skin aging or pigmentation, laser resurfacing can be
practiced in a single pass to obtain skin tightening [15]. The
octagonal pattern is selected for this fractional resurfacing
with the same CO2 laser, size 3, #5 density, at a pulse rate of
100 Hz and a fluence of 125 J/cm2 (Fig. 6). With these set-
tings and one or two passes, good results are achieved in
complete safety [16], but careful maneuvering with the CO2
laser should be performed to avoid excessively tensing the
lower lid, especially in those patients presenting proptotic
globes. In these cases, fractional CO2 laser, as a less
aggressive resurfacing procedure, should be the selected
option (Fig. 7).
3.1.2 Lateral Canthal Tendon Shortening:
Canthotomy
Canthopexy of the lateral canthal tendon is not always suffi-
cient, and a partial section of the tendon may be necessary. In
fact, the lateral canthal tendon firmly holds the upper and
lower lids running from the tarsus to the periosteum of the
orbit. In the case of the lower eyelid, the canthal tendon is
attached to the fibers of the tarsus. Therefore, the pretarsal
fibers of the orbit are directed and held by the tendon, which
M.A. Trelles
eyelid surgery on males should be conservative, regarding skin elimina-
tion in order to avoid feminizing the aspect of the eye. Note the excel-
lent retraction in the lower eyelid skin and the rejuvenated aspect
achieved for the whole face
is firmly adherent to the lateral orbital rim. Lower eyelid lax-
ity exposing the sclera can be a consequence of stretching or
dehiscence of the canthal tendon. Often, lower eyelid laxity
can be associated with epiphora, which is usually related to
internal canthal insufficiency. When laxity is severe, a typical
transconjunctival blepharoplasty or laser resurfacing to coun-
teract lower eyelid flaccidity is normally a safe procedure
when performed with the aid of the CO2 laser, can worsen this
situation, and cause sclera exposure or ectropion (Fig. 8).
In the case of ectropion, an inversion of the lower lid and/
or the lower lachrymal punctum is noticed and becomes the
cause of epiphora. This situation is accompanied by watering
eyes due to difficulties in tear transit to the lacrimal duct
(Fig. 9).
If lower blepharoplasty via cutaneous access is carried
out, sclera show or ectropion can be common complications
due to excessive skin removal, ignoring canthal tendon laxity
and its necessary adequate repositioning.
To correct lower eyelid laxity, horizontal shortening of the
lid by tensing the lateral canthus is carried out following a
conventional surgical technique, but CO2 laser offers advan-
tages. For this, the lateral canthoplasty is designed with the
aid of the CO2 laser, using the tarsal band technique, in a
simple, elegant, and bloodless procedure. To start the sur-
gery, the lower eyelid is anesthetized using 2 % lidocaine
with 1:200,000 epinephrine. An external canthotomy is per-
formed using the CO2 laser in focusing mode with CW
emission at 7 W. The incision extends to the orbital rim, and
thanks to the CO2 laser, a bloodless surgical field is obtained
with clear identification of the external orbital rim when
exposed. A small flap of periosteum is detached and then a
band from the lower lid is cut with the laser, parallel to the
line of the eyelash as at the level of the gray line. Two dissec-
tion levels are carried out: one external, including skin and
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1137

a c

d e

Fig. 6 Fifty-six-year-old male Fitzpatrick phototype IV. (a) Lower
eyelid bags, cutaneous flaccidity, and redundant upper lid skin. (b)
During resurfacing treatment with the CO2 laser, immediately after
transconjunctival lower lid surgery and upper blepharoplasty. (c) Aspect
3 weeks after treatment. (d) Lateral view of before surgery. Redundant
upper eyelid skin, and prominent fat bags are noticed in the lower lids.
(e) No pigmentary skin reaction and good aesthetic results. Notice the
lower eyelid definition, maintaining a correct position after surgery in
relation to the corneal limbus

a b

Fig. 7 Female, 38 years of age, Fitzpatrick phototype III, presenting tightening, may worsen sclera show. Resurfacing should avoid laser
with periocular lax and wrinkled skin. (a) Prior to treatment, observe the passes on the area of the external canthus of the eye. (b) At 4 days after
evident lateral sclera show due to mild exophthalmos without clinical fractional CO2 laser treatment with Pixel™ mode (Alma™ Lasers). The
manifestations. This condition, when using laser resurfacing for skin skin has been tightened without worsening the scleral appearance
1138
a b
Fig. 8 Fifty-year-old male, Fitzpatrick phototype II, suffering severe
periocular skin laxity with prominent lower eyelid bags and redundant
skin in the upper lids. (a) Prior to treatment, note the surplus of skin and
evident festoons covering the malar area. (b) Eight days after treatment,
the excess skin of the upper lids has been excised with the aid of the Co2
Fig. 9 Seventy-six-year-old patient, Fitzpatrick phototype
III. Anatomical aging changes are noticed in the symmetry and lateral
canthi of both eyes. The lacrimal duct should be at a lower level than the
lateral canthus. The lower eyelid presents an inversion of position due
to lateral canthal tendon laxity. In the right eye, there is a mild ectro-
pion, and in the left eye, epiphora causes a constant weeping of the eye.
Fat bags are in the lower lids; however, the upper lid keeps its anatomi-
cal design quite well. Surgical repair should tighten both lateral canthal
tendons
muscle, and another internal, including the tarsus and con-
junctiva which will be the tarsal band. Using the CO2 laser
with pulses of 30 ms at the same power, deepithelization of
the tarsal internal level is performed to eliminate the con-
junctival layer (Fig. 10).
Once this preliminary process is finalized, the length of
the tarsal band is checked to obtain a desirable tension and is
then attached to the orbit. Next, the tarsal band is sectioned,
shortening it to an appropriate length, also using the CO2
laser in CW at the same power. Suturing is done with two 5-0
nylon stitches, avoiding excessive tension so as not to pro-
duce entropion.
When the eyelid skin is repositioned, any redundancy is
eliminated by cutting it with the laser to match the lateral
canthus. The CO2 laser is once again part of the surgery to
M.A. Trelles
laser, and the lower lid fat bags have been removed via the conjunctiva.
Then, CO2 laser resurfacing was performed on the lower lid skin. The
skin has clearly recovered showing a correct conformation of the upper
lid arch, without feminization. The lower eyelids present an excellent
aesthetic outcome with adequate skin tension
eliminate excess skin [17]. For this, it is programmed in
pulsed mode to obtain tissue tightening. In defocusing mode,
7 W power in pulses of 30 ms nicely controls RTD, “ironing”
the skin to get rid of wrinkles [15].
At the end of surgery, the lateral canthus should be
checked for its correct position, which should be approxi-
mately 2 mm over the horizontal level of the medial canthus,
so that normal tear drainage can be recovered by the lacrimal
punctum. To finish, the skin which continues the lateral can-
thus is closed in two layers with 6-0 Vicryl™ (Fig. 11).
3.1.3 Eyebrow Lifting Via Upper
Blepharoplasty
Upper eyelid blepharoplasty assisted by the CO2 laser is a
well-established surgical procedure with benefits over the
traditional cold scalpel approach [18]. When it comes to
operating in a bloodless field, advantages can be appreciated,
thanks to the CO2 laser, since the identification of all ana-
tomical plains enables performing clear surgical steps and
hence, success.
In upper blepharoplasty, not all patients benefit enough
from the elimination of redundant lid skin. Complementary
brow elevation enhances this surgery, improving the surgical
outcome [19].
But, when dealing with eyebrow elevation, fixation of the
soft tissue related to the forehead is still one of the least
controllable and least predictable stages of the surgery, espe-
cially when eyebrow tail lifting is to be carried out [20].
Techniques with suture or percutaneous fixation, using
screws, often lead to limited results [21].
The Endotine™ blepharoplasty implant (Coapt
Systems Inc., USA), made of polylactic acid, is an effica-
cious solution to achieve eyebrow fixation, completing the
upper blepharoplasty procedure. This biodegradable
implant provides suture-free fixation, facilitating a mini-
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1139

a b

Fig. 10 Sixty-eight-year-old male, phototype III. (a) Prior to lower
blepharoplasty and correction of the lateral canthal tendon laxity. Note
the exposure of bilateral sclera with slight epiphora and constant eye
weeping. Evident lax skin and prominent bags. (b) Fat bags have been
removed transconjunctivally, and an external canthotomy was carried
out in the left eye in order to shorten the tendon to correct the sclera
show. In the right eye, the external canthal tendon was shortened by
plication to raise the external canthus. Note the excellent anatomical
recovery and aesthetic result

a b

Fig. 11 Seventy-four-year-old male, Fitzpatrick phototype IV. (a)
Evident upper eyelid skin laxity and dermatochalasis which reduce his
field of vision. The presence of fat bags in the lower eyelid and cutane-
ous festoons covering malar areas. (b) One month after CO2 laser sur-
gery, a good aesthetic result in the upper eyelid with removal of
redundant skin. In the lower eyelid, fat bags have been repositioned,
with the aim of giving volume and to avoid the sinking of the eye. The
festoons were eliminated by excision and skin lifting. Sutures were hid-
den by placing them on one of the crow’s feet wrinkles. Excellent aes-
thetic rejuvenation results with high patient satisfaction

mally invasive procedure with reduced surgical time. The

Endotine™ surgical reabsorbable material lasts for a
period of around 8–10 months, leaving fibrosis that
anchors the eyebrow tail in its new elevated position. The
implant is designed with three hooks which when in place,
suspend the eyebrow. Surgery is done under local anesthe-
sia, and the device is placed via the upper blepharoplasty
incision. During surgery, the supraorbital rim is easily
exposed with the aid of the CO2 laser operating in CW. A
blunt instrument is used to elevate the periosteum, sepa-
rating it from the bone surface; then, the implant is placed
fixing it directly to the bony part. Fixation is performed by
introducing the implant pin into a surgically drilled,
made-to-measure hole. The base of the implants main-
tains good contact and adapts to the frontal bone, and eye-
brows are elevated and engaged with the hooks
incorporated in the absorbable device (Fig. 12). Fig. 12 Detail during surgery for the elevation of the tail of the eye-
Suturing is carried out as in conventional upper blepharo- brow using an endoprosthesis (Endotine™). Placement of the device
was done at the time of upper eyelid blepharoplasty. Direct access to the
plasty with Vicryl™ 6-0, and it is advisable to use a com-
frontal plane is facilitated with the CO2 laser, reaching the frontal bone
pressive circular bandage on the forehead for a period of 5 for implant attachment. The whole intervention is under local anesthe-
days, to hold the implants in place (Fig. 13). sia, and the CO2 laser provides a blood-free surgical field
1140 M.A. Trelles

In only one surgical procedure, upper blepharoplasty and
eyebrow elevation can be done, simplifying surgical aes-
thetic eyebrow lifting, avoiding specific procedures neces-
sary for this surgery, as in the case of frontal or endoscopic
lifting [22]. The combination of upper blepharoplasty and
eyebrow elevation permits two surgical procedures that
nicely rejuvenate the periorbital appearance (Fig. 14). Low
eyebrow position is corrected thanks to the Endotine™
implants which are also well indicated for those patients pre-
senting moderate ptosis and for those who refuse to undergo
conventional surgery to lift the forehead (Fig. 15).
The efficacy of upper blepharoplasty and brow lifting,
especially when it comes to tail position, becomes optimal
with the aid of the CO2 laser; moreover, postsurgical discom-
fort and tissue repair do not require any longer recovery time
than for upper blepharoplasty alone.

4 IPL Treatment to Improve Skin

Condition in the Case
of Stretch Marks

Infrared light systems produce collagen-related effects

Fig. 13 Patient immediately after upper blepharoplasty and lifting of
the tail of the eyebrows using the Endotine™ prosthesis. The patient is
wearing the tape on the frontal area to exert pressure and keep forehead
tissue in its new position
enabling the treatment of several skin disorders and facial skin
rejuvenation [23, 24]. We use this treatment in various ses-
sions, following our reported experience to enhance the condi-
tion of stretch marks and improving skin appearance [25].
Striae distensae are a very common cutaneous lesion for
which treatment remains a challenge. In the early stages,
striae appear pink to red (striae rubra) but over time become
atrophic and white (striae alba). Both stages of stretch marks
represent a distension (distensae) of tissue fibers [26].
Histologies show that striae distensae are similar to scars
with a thin flat epidermis, attenuation of the rete ridges, fray-
ing and separation with loss of parallel orientation of colla-
gen bundles, and dilated vessels [27]. Tissue changes are as
a consequence of body weight changes, corticosteroid ther-
apy, Cushing’s syndrome, infections, and hormonal factors
such as puberty and pregnancy [28].
Treatment is carried out with high fluence and high
frequency with stacked pulses of infrared (IR) IPL on areas
presenting this skin disorder. Within our program of
treatment, IR is used in combination with chemical peels that

a b

Fig. 14 Fifty-eight-year-old
female, Fitzpatrick phototype III.
(a) Prior to treatment, redundant
skin in the upper eyelids. The
aperture of the eye is reduced
and sagging eyebrow tails are
noticed. (b) Two weeks after
treatment, excellent aesthetic
results with restoration of the
upper eyelid arch. Eyebrow tails
have been raised giving the
whole face a better aesthetic
appearance
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery
a b
Fig. 15 Thirty-two-year-old female, Fitzpatrick phototype II. (a) Prior
to treatment, her eyes presented a sad expression, and redundant upper
eyelid skin makes the patient lose the anatomical and aesthetic arch,
Fig. 16 Treatment of post-
a b
pregnancy striae distensae in a
35-year-old, Fitzpatrick
phototype III. (a) Prior to
treatment, note the marked
cutaneous distension and stretch
marks. (b) Effect after six IPL
treatment sessions. The skin’s
texture has improved and stretch
marks are less noticeable
include glycolic and ascorbic acids and also two to three ses-
sions of 585 nm pulsed dye laser to decrease redness in the
lesion and to stimulate collagen. This combination shows
beneficial effects against stretch marks [29, 30].
The IR controlled pulsed light source sessions produce
clinical improvement and collagen remodeling, as occurs in
the case of atrophic facial scars and fine wrinkles [31]. IR
broadband pulsed light (Nova Plus; Nova Light, Switzerland)
in combination with light chemical peels and 585 nm pulsed
dye laser sessions helps against the multifactorial origin of
stretch marks. As we have communicated, this treatment
helps plastic surgeons as a complementary treatment, for
example, in cases of abdominoplasties [25].
We carry out four treatment sessions with an 800–
1,800 nm band width at a fluence of 31 J/cm2. The pulses of
light are delivered in a chopped mode as a series of mini
pulses to avoid skin burning and to safely build up a solid
thermal deposit in tissue. Pulses are from 6 ms, with a delay
time of 20 ms and a repetition rate of 0.5 Hz.
Patients inform us that they obtain better skin texture and
improved condition of the treated area (Fig. 16), but, in order to
ascertain results objectively, a follow-up with images of before
and after are recommended to provide objective evaluation and
support to the measurement of the quality of results [32].
Photographs are taken at baseline and at the final session. Stretch
1141
especially in the right eye. (b) One year posttreatment, the eliminated
surplus skin and recovery of the upper eyelid arch give a correct aes-
thetic result, with a younger expression
marks are outlined using a pixel-based algorithm with computer-
generated data, thanks to an operator-based edge detection pro-
gram (Fig. 17). The before and after condition of stretch marks in
the treated area, when compared, typically shows improvement
(Fig. 18). However, the total disappearance of stretch marks is
not expected, rather an improvement in the appearance of the
skin and a reduction in the width of “cracked” tissue. Favorable
changes to skin condition are noticed from the third session and,
according to our controls, maintained for 3–6 months. So, it is
advisable to recommend that patients undergo one or two main-
tenance sessions every 6 months to sustain the results achieved.
Changes in the aspect of the striae are a consequence of a
decrease in skin roughness. Therefore, a combination of chemical
peels and sessions of 585 nm flash pulsed dye laser enhances
results. By adding these treatments, the microcontours of stretch
marks are improved. Particularly, we find that the use of 20 %
glycolic and 10 % ascorbic acid is an effective complement
[33, 34]. In addition, treatment with the 585 nm pulsed dye laser
at 8 J, with 12 ms pulses, reduces the reddish color of the stretch
mark to blend in better with the surrounding tissue color, and, at
the same time, these sessions improve collagen deposit in dermis.
Stretch mark treatment may be a more relevant subject for
dermatologists rather than plastic surgeons, but there are
implications regarding the impact that this skin disorder has
as a part of the whole patient in aesthetic surgery.
1142 M.A. Trelles

Fig. 17 Corresponds to digital camera analysis of the skin surface A,
1,2,3 represent before treatment. B, One month after the 6th session.
Photographs of the same treatment area are analyzed using a com-
puter program. Before and after correspond to analysis of photographs
of patient in Fig. 16, for possible changes in characteristics of a
stretch mark. A1 corresponds to the skin surface, and A2 is the same
image but in 3D. B1 and B2 correspond to 1 month after six treatment
sessions. Improved skin texture is noticed, and the 3D image shows
this evidence further. A3 and B3 compare the data from before and
after on graphs, representing skin roughness. This objective method
of analysis enables a precise follow-up of benefits of IPL treatment
sessions

Fig. 18 Twenty-seven-year-old
a b
patient, Fitzpatrick phototype IV.
(a) Post-pregnancy, prior to
treatment, she had evident stretch
marks and lax skin. (b) One
month after six treatment
sessions. An improvement of
skin texture and stretch marks
can be noticed

5 Fractional Laser Resurfacing
Combined with Chemicals
for the Treatment of Troublesome
Facial Skin Pigmentary Disorders
In general, facial skin pigmentation changes are a difficult
entity to treat. Creams or peels ensure some success, but
recurrence is often seen because skin seems to adjust to treat-
ment after some time of using creams with no further
effective reactions being noticed [35, 36]. Such devices as
the Q-switched Nd:YAG, the alexandrite, and the Er:YAG or
CO2 lasers are used, but in darker skin types, the risk of sec-
ondary hyperpigmentation is high [37]. IPL devices have
also been proposed, and more recently, fractional resurfacing
treatments have proved effective.
We consider that a combination of both lasers and a main-
tenance program with the application of creams works much
better, if periodic revision of the skin status is carried out in
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery
a b
Fig. 19 Patient, 38 years of age, Fitzpatrick phototype IV. (a)
Pigmentation around the mouth and signs of skin aging. (b) Results of
fractional laser resurfacing with the CO2 laser (Active™ Lumenis™) 1
order to adjust treatment [38]. In this sense, epidermal dark-
ening by pigment is partially removed together with keratin
by the mechanical microabrasion of exfoliants in the form of
creams. Alpha hydroxy acids (AHA) or superficial light
peels with acetylsalicylic acid become useful in removing
the superficial skin layer [39]. This chemical peel eliminates
the superficial keratin skin layer facilitating the action of
maintenance creams [40].
The program we use to keep skin pigment under control
for difficult disorders such as melasma [41] is a combination
of pulsed CO2 laser fractional resurfacing with a mainte-
nance program of creams which is initiated once skin is
totally reepithelized [42].
Melasma patches are found in the centrofacial, malar, or
mandibular/mental regions with pigment located both in epi-
dermis and dermis. The etiology of melasma remains largely
unknown, but has been associated with eccrine, paracrine,
hormonal factors, genetic predisposition, pregnancy, use of
oral contraception, stress, and exposure to solar or other UV
radiations [43].
The pulsed fractional ablative CO2 laser (UltraPulse™
Encore, Lumenis, Israel) achieves clearly sustained efficacy
when combined with chemical peels. In our experience, laser
1143
month after. (c) Shows trials with various densities of laser pulses to
define the suitable treatment before resurfacing
treatment of melasma complemented by a program of creams
can be assumed as a frontline treatment.
The CO2 laser wavelength is well absorbed by the skin
where both the epidermis and dermis are high in water con-
tent. This chromophore acts as a target and as a limiting bar-
rier to prevent over-penetration when using the settings of our
treatment program [44]. Positive treatment for mixed melasma
should be expected, especially when pigment involvement is
seen in the epidermis and in the superficial dermis. The
parameters we use are 11.3 J/cm2, 50 Hz nonsequential repe-
tition rate of pulses of 350 μs. With these settings, incident
power of 7.5 W programmed over a hexagonal pattern (No. 1,
size No. 5, and pulse density No. 2, gives 70 × 500 μm diam-
eter shots per pattern cycle) is highly efficacious. The power
density per shot is just over 3,500 W/cm2, and the energy and
radiant fluence per pulse is of 150 mJ, at a frequency of 50 Hz
and 11.3 Jcm2, respectively. In fact, treatment is given at high
power and low energy density using the so-called cool mode,
which corresponds to a nonsequential form of treatment in
which the laser pulses are not delivered adjacent to the previ-
ous pulse on tissue (Fig. 19).
RTD in the dermis produced by the CO2 laser treatment,
with the aforementioned parameters, does not pose a problem
1144 M.A. Trelles

a b c

Fig. 20 Patient, 39 years of age, Fitzpatrick phototype III. (a) Typical (Active™. Lumenis™) followed by cream maintenance treatment. (c)
cutaneous pigmentation of melasma, particularly in the upper lip. (b) One year after treatment, the good effects achieved persist
Result 1 month after treatment with a CO2 laser in fractional mode

Fig. 21 Patient, 29 years of age,

a b
Fitzpatrick phototype IV. (a) Melanosis on
the forehead and signs of cutaneous
pigmentation on the whole face as a result
of frequent sun exposure. (b) Results 2
months after superficial resurfacing
treatment with the Er:YAG laser and
antipigment cream for maintenance.
Improved skin texture and good resolution
of pigmentation

when treating melasma. There is no exacerbation of pigment,
in the follow-up over a long period, when fractional nonse-
quential resurfacing is used in combination with creams.
Such combination obtains excellent results and prevents pig-
ment recurrence (Fig. 20). Therefore, it is mandatory for
patients to pursue the cream maintenance program over the
long term.
The CO2 laser in fractionated mode features a
microprocessor-controlled pattern generator which allows
defining the shape and size of the area of tissue treatment.
Pulse density can also be chosen according to a single
pattern cycle. Individual pulses delivered in a quasi-random
nonsequential mode avoiding superimposition of RTD
effectively control the increase in thermal gradient in tissue
and the residual heat deposit (Fig. 21). This effect is first
reinforced by the ultrashort 350 μs pulse, far shorter than
tissue thermal relaxation time, and, second, the low fre-
quency of pulses (50 Hz) delivered to the skin target also
helps to avoid spot superimposition and buildup of thermal
effects.
During treatment, the epidermis and a fine layer of
superficial dermis are eliminated in a single laser pass
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery
a b
Fig. 22 Remodeling of the ear. (a) During Er:Glass laser pulse treatment of the helix to soften cartilage. (b) The mold, carried out with a resin
impression to maintain the ear, with slight compression, in its new position, thanks to a simple bandage as seen in (c)
Fig. 23 The patient is wearing the mold in position in the treated ear
prior to applying the bandage
which produces quite deep, but very narrow zones of pho-
tothermolysis damage with a typical “spike” formation in
tissue due to the Gaussian nature of the CO2 beam. Judging
from the results we obtain with our treatment program, the
depth of penetration reaches the dermal melanophages, in
the case of mixed type of melasma [45], which is not the
case in other systems such as the Q-switched alexandrite
laser [46].
Once crusting had fallen off, subjects are directed to apply
an antipigment cream, as night treatment, with the following
ingredients: glycolic and kojic acids, vegewhite, salix alba,
vaccinium myrtillus, and aloe vera (TT2™ Antipigment
Cream, Laboratory Profarplan, Barcelona, Spain). In addi-
tion, regular moisturizers and, when outdoors, solar protec-
tion are indicated during the day [47].
1145
c
6 Laser Cartilage Reshaping
as an Alternative to Surgical
Otoplasty
Deformed ears and abnormal position of ears with respect to
the head are common congenital aesthetic conditions with a
well-known hereditary component. Separated ears can be the
cause of psychological anxiety from childhood onward.
Surgery is encouraged before the child reaches school age.
Otoplasty is a demanding procedure and a common surgical
intervention. We have demonstrated [48] that the Er:Glass
laser can be used to correct ear malformation reshaping the
ear cartilage with no skin incision or surgical procedure [49].
Treatment is carried out without any anesthesia on the
entire helix and the concha. All areas are irradiated on both
sides with a 1,540 nm Er:Glass laser (Aramis™, Quantel
Medical, Clermont Ferrand, France). The laser treatment is
given at 12 J/cm2 per pulse, seven pulses (3 ms, 2 hz-84/cm2
cumulative fluence), applied with a 4 mm spot handpiece
integrated in a cooling device (Fig. 22).
After irradiation, a silicone elastomer used for dental impres-
sion is inserted inside the helix and the concha in order to bring
the ear to the desired new position (Fig. 23). This mold is main-
tained for 15 days by means of a bandage wrapped around the
head. Paracetamol, 500 mg every 8 h for 2 days, is the only medi-
cation prescribed. Follow-up of over 2 years has proved that ear
reshaping remains in place without recurrence (Figs. 24 and 25).
7 Breast Reduction with the Aid
of the Er:YAG Laser
in the Deepithelization Stage
The deepithelization stage of breast ptosis and breast reduc-
tion surgery is important and can be associated with risks
that could affect the final results [50]. Although many
1146
Fig. 24 The effect of laser treatment on a
a b
patient of 24 years of age, Fitzpatrick
phototype III-IV. (a) Before, ears slightly
separated. (b) Two months after laser
treatment, the separation of the ears can be
seen corrected
Fig. 25 Patient, 69 years of age, Fitzpatrick phototype III. (a)
Separation of the left ear. The reticulated screen enables the apprecia-
tion of the closing or the separation of the treated ear in respect of the
techniques for reduction and correction of breast ptosis have
been described, none of them is accepted as the “gold stan-
dard.” No single technique is suitable for all types of breast,
but all of them go through deepithelization.
During surgery, significant side effects such as bleeding,
infection, cyst formation, skin necrosis, and scarring could
compromise the outcome. In spite of this, the majority of
surgeons use a manual technique, dissecting off the required
M.A. Trelles
cranium. (b) This shows the result 6 months after laser treatment.
(c) The improvement in the position obtained by treatment is main-
tained 2 years after
area of skin with a scalpel. This requires considerable man-
ual dexterity to remain on the appropriate plane and save the
superficial vascular plexus. Also, different levels of dissec-
tion can be produced going to too deep a plane and injury to
the dermal pedicle or too superficial a plain with incomplete
removal of epidermis leading to cyst formation. Moreover,
bleeding can be a problem and requires extra time for careful
hemostasis.
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1147

Fig. 26 Breast reduction

a b
surgery. (a) Marking is
performed. (b) Result of
deepithelization performed with
the Er:YAG laser. Note the good
condition of the dermis. The
epidermis has been rapidly
eliminated avoiding bleeding and
respecting the superficial
vascular plexus of the breast

Fig. 27 Before and after

photographs of the patient in
Fig. 26 in which deepithelization
was done with an Er:YAG laser.
A1 and A2, Before. B1 and B2,
results 1 month after

Having practiced the stage of deepithelization using the
Er:YAG laser in breast reduction surgery, we find this
approach to epidermis elimination in the skin flap a safe, pre-
cise, effective, and side-effect-free method, which becomes
particularly important for the less experienced surgeon
(Fig. 26).
Surgery is performed following the traditional inferior
pedicle or the Peixoto technique [51] after modeling with the
Wise pattern design, also in case of vertical scar incision [52].
Patients are operated on under general anesthesia, with breast
infiltration of lidocaine 0.05 % with epinephrine 1:100,000
diluted in 1,000 ml of saline solution.
In the case of inferior pedicle deepithelization with the
Er:YAG laser, we use a collimated 3 mm handpiece, with
350 μs pulses at a fluence of 28 J/cm2 and a repetition rate of
10 Hz with a 50 % overlap, giving the equivalent of two
passes with a single pass. These settings are based on our
own experience, which confirms efficacious removal of the
whole epidermis in other cutaneous conditions [53].
In vertical scar mammoplasties, the vertical flap is deepi-
thelized and the incision performed downward to the pecto-
ralis major muscle. In cases of slight ptosis and hypertrophy,
the periareolar technique is used to correct the mastopexy, as
described by Sampaio [54]. In these cases, skin is excised
around the areola. The areola is not separated from the body
of the gland, and the cutaneous excision follows the skin’s
natural lines of cleavage and tension.
Deepithelization with the Er:YAG laser generates practi-
cally no bleeding, and none of the patients treated suffered
from areola-nipple necrosis (Figs. 27 and 28).
1148 M.A. Trelles

Fig. 28 Patient, 49 years of age,

a b
Fitzpatrick phototype III. (a)
Hypertrophic ptotic breasts. (b)
One month after surgery, with
deepithelization performed with
the Er:YAG laser

Fig. 29 Patient, 64 years of

a b
Fitzpatrick phototype III. (a)
Rhinophyma. The deformity and
the width of the tip of the nose
can be seen. (b) One month after
CO2 laser treatment to remodel
the nose and remove the
hypertrophic tissue. The
harmony of the reduced tip of the
nose has been restored

The Er:YAG laser permits deepithelization almost three
times faster than the use of a conventional scalpel, and most
of this difference is in the time required to achieve a dry field
in the breast. The precision of Er:YAG deepithelization
allows the removal of the epidermis with practically no
bleeding as the energy hardly penetrates into the papillary
dermis, thus offering the surgeon safe surgical precision. In
fact, vaporization of the epithelium using the CO2 laser has
proved efficacious in numerous clinical experiments; how-
ever, the negative effects of the peripheral secondary thermal
damage must be taken into account during the wound heal-
ing stage [55].
8 Other Complementary Applications
Such as Nose Reshaping and Lip
Rejuvenation Combining Laser
Resurfacing, Fillers, and Skin
Resurfacing
8.1 Nose Reshaping
The characteristic, multiple hypertrophic nodular formations
of rhinophyma, located at the distal position of the nose, are
very appropriate indications for CO2 laser vaporization offer-
ing several advantages [56]. Usually, nodular tissue
formation, which can eventually become peduncular, starts
after the ages of 40–50 years. Pilosebaceous glands are
hypertrophic, with fibrotic inflammatory images and with
telangiectasia formation.
To treat these lesions, local anesthesia with lidocaine is
injected to block the circle of the whole nose. Then, the
UltraPulse™ CO2 laser (Lumenis, Yokneam, Israel), pro-
grammed at 25 W, is fired in periods of 20 ms, with a delay
time of 300 ms, to remove tissue cleanly and without bleed-
ing. Treatment is conducted using a 1 mm spot handpiece,
slightly defocused, to avoid “pinholing” tissue. Laser deb-
ulks overgrowth tissue, full of keratin and sebum, reducing
the excessive volume of the nose, leveling it down.
Hypertrophic glands are vaporized, and at the same time, due
to the thermal propagation effect as a consequence of
repeated laser pulses, telangiectasias are also effectively
resolved [57]. In fact, the water chromophore, absorbing at
the 10,600 nm wavelength, serves as a barrier to laser energy,
constraining its thermal effect with great precision, so that
neighboring tissue helps rapid skin restoration with excellent
cosmetic results (Fig. 29).
As described in the previous block, following surgery, we
use LED therapy sessions, to speed up tissue healing [58].
According to our observations, this photo-treatment would pre-
vent scarring and obtain very natural skin repair [12]. No dress-
ing is used, just an ointment composed of retinyl palmitate,
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery
b
a c
Fig. 30 Patient, 32 years of age, Fitzpatrick phototype II. (a)
Rhinophyma. The hypertrophic glandular cutaneous tissue slightly
diverts the nose toward the left. (b) Two months after removing the
DL-methionine, and gentamicin (Novartis Farmacéutica, S.A.,
Barcelona, Spain) three times a day until scabs fall off. Redness
is usually observed in treated areas, which are easily camou-
flaged with colored sun protection (Fig. 30).
8.2 Lip Functional Restoration
and Rejuvenation Combining Small
Surgical Procedures, Laser Resurfacing,
and Fillers
From the literature, it becomes very clear that the CO2 laser
is associated with better, longer-lasting results than other
ablative lasers, also from the point of view of enhanced col-
lagen remodeling, but produces longer-lasting side effects
[59]. Also, the CO2 laser has no competition from other
lasers when it comes to hemostasis, wound contraction, and
a better deposition of RTD associated with a tighter,
1149
cutaneous-glandular excess with the CO2 laser and remodeling the
shape of the nose, slight residual erythema can be observed. (c) Aspect
3 days after treatment: thick scab on the whole treated area
younger-appearing epidermis and better long-term mainte-
nance of the results obtained [60, 61]. However, one disad-
vantage of using the CO2 laser is prolonged erythema after
surgery, but this setback can be well controlled with the help
of colored cosmetics [62]. In fact, side effects, both in extent
and duration, are well accepted by patients, because there is
no perioperative bleeding or discomfort, pain, or exudation
which is usually associated with settings of other more pre-
cise ablative lasers such as the Er:YAG [63].
Burn scars have unique characteristics, especially when
they are located on the lips. The different significant depths
and areas of lesion joining one scar to another deform the lip
and its functional and cosmetic condition. The number of
viable pilosebaceous units makes lip scars different to other
burn scars and also makes it necessary, at the time of repair,
to take into account not just the margins of the burn but the
whole skin and muscle structure, which requires a signifi-
cantly different treatment [64, 65].
1150 M.A. Trelles

Fig. 31 Patient, 27 years of age,

a b
Fitzpatrick phototype II. (a) Scar
tissue, sequela of a burn suffered
in childhood. Retraction of the
lower lip, hypertrophic scars, and
fibrotic tissue. (b) Results after 5
treatments combining CO2 and
Er:YAG lasers and reconstructive
surgeries of the lip to improve
symmetry. Good quality of
functional and aesthetic results

Fig. 32 (a) Residual scar,

a b
atrophic tissue, and the absence
of hair on the upper lip after
tumor removal. (b) Result of CO2
laser surgery to remove cicatricial
tissue approaching the edges.
Surgery was followed by skin
resurfacing with the Er:YAG
laser. Hair growth is normal, and
lip symmetry and volume were
achieved by a hyaluronic acid
filling

The shape and size of the lips play an important role in the
aesthetic balance of the lower part of the face. Their charac-
teristics of youthful appearance are lost with age, but also
scarring makes the lips lose turgidity, volume, and functional
standards, and skin vitality becomes rigid and fibrotic [66].
Scarring can occur in the lips due to chemical or mechani-
cal peels, accidental burning, and even as a consequence of
the wrong laser resurfacing approach during the treatment of
wrinkles with lasers [67]. Because there is practically no
subcutaneous fatty tissue in the lips, the muscle fibers are
particularly influenced by the retraction undergone by the
dermis due to wrongly controlled therapeutical aggression.
In past years, we have used the CO2 laser for scar revision,
programming high power in short pulses and a relatively
long delay time of 300 ms between pulses. The settings we
find suitable for treatment are 25 W, with a spot size of 1 mm
and pulses of 20 ms [68].
For treatment, first, the elevated scar tissue located on the
lip is carefully debulked, progressively smoothing the whole
scarred area defining penetration to avoid the orbicular mus-
cle. Once elevation is equal to the surrounding area, laser
treatment is stopped. If scarring is severe, a few sessions of
treatment will be required, but lasting and beneficial effects
are achieved as demonstrated at long-term controls (Fig. 31).
Preparation of patients is fundamental in order to rec-
ognize and accept the necessary compliance with the
posttreatment skin care regimen, which fundamentally
consists of an ointment, based on retinyl palmitate and
gentamicin (Pomada Oculos Epitelizante, Novartis
Farmacéutica, S.A., Barcelona, Spain) to help epitheliza-
tion and to prevent infection, applied three times a day
until scabs detach.
Reconstruction of lips to recover aesthetic design
may require conventional surgical techniques such as the
excision of damaged scar tissue. Careful suturing fol-
lowing the rules of aesthetic surgery will result in a more
suitable pattern of beauty. Once surgical repair is
achieved, tissue aspect can be improved by phototherapy
sessions and scar refinement. All surgical procedures are
carried out with the CO2 laser and sessions of quasi-
monochromatic 633 nm phototherapy (Fig. 32 ). Once
scarred skin has been corrected to a maximum, other pro-
cedures can be implemented by small advancement flaps
and the use of fillers to elevate tissue gaps and give the
lip volume (Fig. 33 ). If this is the case, we use hyal-
uronic acid (Esthelis® Basic, Anteis S.A., Geneva,
Switzerland) injected periodically to recover the cos-
metic appearance.
Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery 1151

a b

c d

Fig. 33 Patient, 56 years of age, Fitzpatrick phototype II. (a) Large
area of scar tissue due to serious complications after trichloroacetic acid
peeling. Scarring presents atrophy, fibrosis, and retraction which pre-
vent the normal opening of the mouth. (b, c) Several stages of recon-
structive surgery with the CO2 and Er:YAG lasers. Three sessions of
perioral resurfacing and one full face resurfacing were carried out
together with surgical delineation of the cutaneous-vermilion. Z-plasty
was also carried out to correct lip asymmetry. (d) Results 2 years later
after the last resurfacing with Er:YAG laser to homogenize the quality
and texture of all of the skin of the face

Conclusions also permits the alleviation of symptoms such as pain,

The ever-changing nature of medical treatments devel-
oped nowadays along with technological progress poses
surgeons with the constant challenge of updating their
knowledge and adopting new techniques. Today, new sur-
gical apparatus makes surgical procedures easier, and
such is the case with the lasers that have entered the medi-
cal arena to improve the surgical armamentarium, expand-
ing opportunities to operate with greater efficacy and to
obtain better results.
Moreover, the use of lasers, and by extension photo-
therapy, IPL, chemical peels, and fillers, enhances the
outcome of conventional surgical aesthetic procedures but
inflammation, and recovery time, especially since nowa-
days a rapid reincorporation to daily duties is of capital
importance.
Undoubtedly, the indication of light as therapy and
laser application in aesthetic surgery is much bigger than
what can be presented in this chapter. In fact, the expanded
influx of technology enables treatment of an increasing
number of pathologies with surgical lasers that were not
previously treatable. This progress offers the chance for
plastic surgeons to proceed much better during aesthetic
treatments and corrective surgery and, in particular, in the
extensive list of cutaneous disorders and tumors. The
1152
combined application of lasers, IPL devices, and LED
therapy described is presented as a treatment alternative
or as a complement to plastic aesthetic procedures to
safely improve surgical outcomes for the benefit and sat-
isfaction of patients.
Acknowledgments The authors hereby declare that they have no
financial or any other interest in the companies and/or equipment men-
tioned in this study.
The conclusions of this study are recorded in the academic activities
of the Antoni de Gimbernat Foundation, 2008–2009.
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 Noninvasive Physical Treatments
in Facial Rejuvenation
Luca A. Dessy
Nowadays, there are many nonsurgical treatment modalities
for facial and body rejuvenation [1]. If we do not take into
account invasive procedures such as chemical peelings, infil-
trative therapies (fillers and revitalizing), needling, or derm-
abrasion, it is possible to identify two main classes of
physical treatments: resurfacing procedures (laser, IPL, etc.)
and therapies finalized to improve the deep dermis, subcuta-
neous tissue, and muscles (massage, radiofrequency, and in
some occasions carboxytherapy). This chapter focuses on
these noninvasive methods that are gaining more interest in
the scientific community, playing a key role in facial rejuve-
nation. Sometimes they may be considered as a good alterna-
tive to invasive procedures, especially in those patients who
refuse or do not tolerate them or, on the other hand, as prepa-
ratory or complementary treatments to be used in association
to surgical procedures. Finally, it is meaningful to underline
the importance of such procedures for a good prevention and
careful management of the patient’ skin, in order to avoid or
delay as much as possible more invasive and debilitating
procedures.
1 Radiofrequency
Human dermis consists mostly of collagen. Collagen is com-
posed by a triple helix, which generally consists of three poly-
peptide chains stabilized by cross-linked bonds. Skin aging
reduces the stability of these cross-linked bonds resulting in
the formation of wrinkles. High-frequency alternating electric
current (ranging from 0.3 to 10 MHz) is a further development
of traditional electrosurgery. It effectively heats and ablates
damaged tissues producing tightening and wrinkle reduction
(radiofrequency tissue tightening) [2, 3]. Over the past several
years, alternating currents with wavelengths in the range of
L.A. Dessy, MD
U.O.C. di Chirurgia Plastica, Dipartimento di Chirurgia,
Università di Roma “Sapienza”, Rome, Italy
e-mail: lucadessy@hotmail.com
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_79
radiofrequency (RF) have been used in medicine for various
purposes such as strengthening joint capsules, molding carti-
lage and bone, cancer therapy, pain relief, etc. [4–6].
Radiofrequency induces a modification in the three-
dimensional conformation of collagen, producing heat when
the tissue’s electrical resistance converts the electric current
to thermal energy deeper within the dermis and biological
tissues. Electric current is generated when the electrons of an
atom flow to the adjacent orbit and its propagation preferen-
tially follows low resistance patterns (mainly nerves but also
tissues rich in water). When electrons find resistance, heat is
generated according to Ohm’s law:
J = I × R×o
(J = energy, I = current, R = tissue resistance, T = time)
Ohm’s law states that the current through a conductor
between two points is directly proportional to the potential
difference across the two points, but it only partially explain
the effects occurring on tissues. In fact sequences ranging
from 1 to 10 MHz generate a phenomenon called electroter-
mia [7, 8]. This frequency range induces a state of activation
of the electrically charged molecules (especially proteins) by
altering the intramolecular bonds so changing protein con-
formation. If high-energy levels are not attained, the process
is reversible.
The process that leads to collagen heating through the
passage of alternating electric current in biological tissues is
therefore complex and elaborated. It is not only determined
by amplitude and frequency, but it also depends on multiple
tissue factors such as the content of electrolytes and water
and temperature. First of all, the heat generated by resistance
breaks the collagen cross-linked bonds and turns the highly
organized crystalline structure that forms the fibrillary sys-
tem in a gelatinous substance [9]. However, several bonds
are heat resistant and do not break, preventing the complete
liquefaction. Thermal denaturation generally occurs over
60–65 °C, depending on the duration of exposure [10]. In
case of reduction of the heat exposure time to a few
milliseconds, temperatures over 85 °C are necessary to break
1155
1156
the cross-linked bonds [11]. Heat is produced for short inter-
vals of time in order to reduce the side effects deriving from
overheating and preserve the epidermis. The first observable
clinical effect is the underlying collagen contraction and new
collagen formation that is critical for tissue tightening and
wrinkle reduction. The contraction of collagen is a reparative
process resulting from a thermal damage, and its progressive
course lasts for weeks.
Moreover, the production of new collagen is related to the
intensity of heating [12]. The biological process that leads to
the biosynthesis of collagen is mediated by two physical
phenomena produced by the RF. Firstly, we have the produc-
tion of a series of heat shock proteins (HSP 60 and HSP 70)
by the connective tissue cells. Subsequently, T lymphocytes
generates the production of cytokines (interleukin IL-1 beta,
IL-6, IL-8, monocyte colony promoting MCP-l) which
attract monocytes that stimulate fibroblasts through the
fibroblast growth factor (FGFI). Fibroblasts are also stimu-
lated to produce matrix through the transforming growth fac-
tor (TGF) beta-l that is synthesized by T lymphocytes.
Furthermore, the tumor necrosis factor (TNF) is produced by
monocytes that recognize the stimulus by HSP, and besides
stimulating the monocytes, it enhances the mitosis of granu-
locytes, inducing them to synthesize colony stimulating fac-
tor (CSF), IL-6, and IL-8. The 6 MHz RF is able to modify
the three-dimensional structure of membrane proteins that
regulate intra-and extracellular flows. In this respect, the
“gap junctional intercellular communication” (GJIC) control
the passage of ions, water, sugars, nucleotides, amino acids,
fatty acids, small peptides, and drugs. In molecular biology,
the 6 MHz RF is used to allow the permeabilization of the
cell membranes, which are exposed to a possible hybridiza-
tion. This process is called electroporation. The heating of
collagen also causes breakage of many intramolecular bonds
that are sensitive to the temperature effect, determining a
modification of the structure of the fibrils. Normally a tem-
perature of 60–65 °C is required to determine the denatur-
ation of collagen and its consequent contraction. The
modified three-dimensional collagen represents a stimulus
for fibroblasts to induce the neosynthesis of a new collagen.
The result is the increase of mRNA that stimulates the syn-
thesis of collagen type l as reported by Zelickson in his report
on histological and ultrastructural evaluation of the effects of
radiofrequency [13].
1.1 Radiofrequency: Therapy
Radiofrequency is a noninvasive treatment for skin rejuvena-
tion that exploits the passage of a high-frequency electromag-
netic energy (alternating current at high frequency, RF)
through the skin. When this energy meets a resistance at the
level of the different tissues, it produces varying amounts of
L.A. Dessy
heat. This ranges in relation to the amount of current, the level
of resistance of the affected tissue, and the characteristics of
the electrodes. Heating the skin up to a certain temperature can
therefore have a positive effect of tissue tightening and wrin-
kle reduction, but it is necessary to reach the deep dermis with-
out damaging the epidermal coat in order to ensure a shorter
recovery period. The ongoing effort to create an optimal
method of skin rejuvenation has led to several new treatment
options. The first applications of alternating current high fre-
quency were based on the use of individual applications with
the aim to obtain the maximum effect possible with a one
single treatment. However, this method presented several
complications that were in contrast with the definition of
“noninvasive” treatment. Therefore, in a few years it resulted
clear that performing repetitive treatments with lower levels of
energy could reduce the incidence of complications and side
effects, with similar results. The development of new tech-
niques and technologies as well as the better comprehension
of the specific mechanisms related to this field of the medicine
led to the concept of targeted treatment, with the selection of a
specific and appropriate method for the individual patient in
order to ensure the safety effectiveness and acceptance of the
procedure. The use of alternating current assumes the pres-
ence of applicators, called electrodes, between which the cur-
rent goes through. Alternating currents passes from a point of
origin to an end-point, following alternating direction.
Therefore, it is always necessary to identify one starting point
(point of entry) and one exit point. The frequency used is in the
range of the radiofrequency from which derives the name of
radiofrequency therapy. In dependence of the type of the elec-
trodes, we differentiate monopolar RF therapy from bipolar
RF therapy (Fig. 1). The main difference between the energy
used in a mono- or a bipolar system is represented by the depth
level of penetration and the side effects. On the other hand, the
cellular effects and mechanisms are basically identical. In a
monopolar system, an electrode specifically designed emits
energy, while a large collector electrode acts as opposite pole
(grounding), allowing the closure the circuit (Figs. 2 and 3).
The advantage offered by this system is that it uses the maxi-
mum density of energy at the level or in proximity of the elec-
trode, with a deeper penetration. However, pain is a
disadvantage. On the other hand, the bipolar systems usually
present very close electrodes so that the amount of energy and
its distribution can be better controlled, with reduced penetra-
tion in the deep tissues.
1.2 Principles of Skin Cooling
Skin coat must be preserved from thermal damage, and this
is possible if the physician manages to be as more selective
as possible while focusing the heat on a specific target, with-
out damages to cutaneous tissues hit by the electrons.
Noninvasive Physical Treatments in Facial Rejuvenation 1157

Mopolar RF surgery Bipolar RF surgery

Genera Genera
RF t RF t

or

or
High resistance to current =
burn
Localised current flux
Current flux Burn possible only between electrodes

Low resistance to current =

no burn

Plate non necessary

Fig. 1 Schematic drawing of the electric loops created by monopolar (left) and bipolar (right) radiofrequency

Contact
electrodes

Cryogen spray Electrical field

Membrane
electrode

2.5 mm
electrical field Epidermis
Dermis

Epidermis Subcutaneous Fath

Dermis
Fig. 3 Schematic drawing of the electric loop created by bipolar radio-
frequency at the level of cutaneous tissues
Subcutaneous fat

and a consequent second-degree burn with skin undermining

Fig. 2 Schematic drawing of the electric loop created by monopolar and clinical evidence of blisters. There are different proce-
radiofrequency at the level of cutaneous tissues dures for skin cooling: cryogenic gas diffusion, skin contact
systems, and cold air ventilation.

When we decide to hit a dermal or subcutaneous structure

such as the connective tissue rich in collagen, where heat is
generated (approximately 4 mm in depth in the case of
6 MHz) and, in absence of a cooling system, its subsequent
diffusion toward the surface would burn the skin.
If the heat produced and absorbed at the level of deep
tissues reaches a certain temperature (over 55°) and time
duration (a few tenths of a second), it may produce a denatur-
ation of proteins present in the dermal-epidermal junctions
1.3 Radiofrequency-Monopolar Therapy
It is a technology that uses monopolar radiofrequency as the
source of energy for nonablative tissue tightening
(ThermaCool TC, Manufacturer: Thermage Inc., Hayward,
California, USA). The prototype of this machine was devel-
oped in 2000 and consists of a generator at high frequency, a
handpiece with different heads, and a cooling system which
1158
Table 1 Schematic table that
indicate for the Aluma® Lumenis
device, bipolar radiofrequency,
the ratio between released power
(from 2 to 10 W) and contact
time (from 1 to 5 s) that generates
an energy expressed in Joule
(from 2 to 50 J)
generates a spray of cryogen before, during, and immedi-
ately after the energy pulse [14]. This technology has been
approved in 2002, by the Food and Drug Administration
(FDA) for the treatment of periorbital wrinkles [15]. In 2004,
the FDA approved the use of this RF also for the treatment of
the face and only in 2007 for the eyelids.
This system generates heat by the tissue resistance to the
flow of electrons (impedance) while creating a uniform, intense,
and sustained volumetric heating in the dermis that denaturates
skin proteins to a depth of 5–6 mm [16]. The presence of a con-
current spray of cryogen spares the epidermis from damage.
With this method, a wider dermal area can be treated with
a single emission. The heating level of the superficial and
deep skin layers is determined by the cooling system, the
size of the handpiece, and the specific impedance of the
treated tissues. Impedance depends on the thickness of the
skin and underlying tissues; the size, distribution, and den-
sity of the connective tissue septa; and the number, shape,
density, and development of skin appendages.
Thermal injury inflicted on tissue is responsible for the
shrinkage of collagen, leading to skin tightening [14–18].
Afterwards, the healing process starts with the remodeling of
collagen type I through the identification of its mRNa. It
results in a cosmetic improvement in 2/3 of the patients who
underwent this procedure [19].
Successively, collagen remodeling begins with the identi-
fication of mRNA of collagen I as in the healing process
[13]. The effects of the treatment develop during a year after
the treatment ends [20].
The procedure appears to be safe and effective in produc-
ing cosmetically acceptable results for the treatment of slight
L.A. Dessy
to moderate wrinkles of the cheeks and nasolabial fold or for
skin tightening after a surgical face lift [21].
1.4 Radiofrequency: Bipolar Therapy
Several new systems consisting in a bipolar handpiece have
been recently introduced to perform RF therapy. But proba-
bly the best innovation was the introduction of a controlled
electrostimulation through functional aspiration (FACES;
Aluma-System, Lumenis Inc., Santa Clara, California,
USA). FACES is a quite interesting technique because it
combines the use of a bipolar handpiece for radiofrequency
to a suction mechanism. The suction allows the lifting of
superficial skin layer in small folds in order to perform a less
painful and more precise stimulation that is localized to a
deeper level. In fact, the handpiece head performs a vacuum
effect with a negative pressure ranging between 8 and
28 mmHg, and the skin is sucked and lifted between the two
electrodes, thanks to the help of a specific coupling gel. The
opening size of the electrodes can be 3 × 18 or 6 × 25 mm.
The RF used is 468 kHz, with power that ranges from 2 to
10 W for a period from 1 to 6 s and a total amount of energy
of 2–60 J (Table 1).
The combination of the mechanical stress performed on
fibroblasts and the direct application of heat produces a posi-
tive effect on the neosynthesis of collagen [22].
The advantage of this system is that we treat a limited
portion of the skin, with reduced energy demand and there-
fore greater safety, less pain complained, and lower inci-
dence of side effects and complications. The parameters of
Noninvasive Physical Treatments in Facial Rejuvenation
this treatment also depend on subjective factors such as the
perception of a single patient to the pinching of the skin,
individual sensitivity to heat, erythema, and pain [23]. There
are several different indications to the treatment: face and
neck rejuvenation (periorbital lines, perioral wrinkles, fur-
rows nasogenal); sagging of the arms, the abdomen, interior
thighs, and knees; acne scars, and stretch marks. However,
any site showing signs of skin aging with superficial or deep
wrinkles and gravitational collapse of the soft tissues can be
treated. It can also be used as an adjuvant treatment in other
surgical and non rejuvenation procedures. Before starting
the treatment, the affected area must be washed with water.
The procedure is performed without anesthesia, and it is
usually painless. Sometimes a slight heat can be felt by the
patients, but it only lasts for a few seconds. Even though
some areas may be more sensitive, hair follicles are not
damaged by the treatment. First, a transparent cream that
prepares the skin and makes it more sensitive to stimulation
is applied. Then, a passage is normally performed on the
whole area maintaining the negative pressure at the mini-
mum level necessary to raise the skin, in order to reduce the
risk of ecchymosis. A double cross passage along perpen-
dicular vectors is also possible. The average duration of the
procedure usually depends on the extension of the area to be
treated.
In the period immediately following the performance,
you may experience some mild erythema in approximately
15 % of the subjects, but it disappears within 2–3 h and
allows to get back immediately to a normal life. In the United
States, it is often defined as “lunch rejuvenation therapy”
because it is usually performed during the lunch interval, and
in about 1 h the patient can return to his/her normal activities.
In fact, in only 5 % of cases, there is a slight edema lasting
several hours, while the risk of burn is estimated at 0.8 %.
Sometimes ecchymosis can also appear due to the action of
vacuum and resolve after about 3–5 days. There are no
reports on permanent scarring as consequence of this proce-
dure. Side effects are generally infrequent and related to the
inexperience of the operator and to the wrong choice of
parameters. Gel or soothing creams, moisturizing and nor-
malizing based on vitamins A, C, and E, can be used. The
application of sunscreens is recommended to protect the skin
and avoid sun exposure during the 48 h after treatment. All
side effects, however, heal without leaving permanent
sequelae [23]. The treatment typically consists of 6–8 ses-
sions every 1–2 weeks with emission of 2–8 W per single
application. Within 6 months, an improvement is generally
observed from moderate to mild in the majority of treated
patients. Currently, the U.S. FDA approved this type of tech-
nology for the treatment of the face, but several studies have
already been published reporting scientific protocols for the
treatment of the laxity of the neck, abdomen, bottom regions
of the arm (triceps), buttocks, and breasts.
1159
The effect of the treatment results in improvements of the
quality of the skin and its characteristics such as tone and
surface. The results are due to the structural renewal of the
skin layers. The new skin is thicker because heated fibro-
blasts are implicated in new collagen formation, subsequent
tissue remodeling, and tone and elasticity restoring, which is
cosmetically beneficial. The tone of the skin then allows the
redefinition of the underlying shapes. The results are usually
immediately perceptible at the end of the cycle and improve
progressively in the 6 months. It is interesting to note that
those patients who do not manifest an obvious result actually
show improvements in the quality of the skin or in the reduc-
tion of skin laxity, when comparing images basal and after
treatment, although such an improvement may be not always
observed by the same subject. For this reason, a careful eval-
uation of the subject’s expectations is important to explain
the real possibilities of improvement, preparing a specific
and illustrated informed consent. The advantages of this
technology (referred to Aluma®) are the absence of pain per-
ception by the patient, the presence of easy handling hand-
piece, rapidity of treatment (about 20–30 min per session),
the almost complete absence of complications, the possibil-
ity of immediate return to normal activities, and overall,
good subjective and objective cosmetic outcomes.
1.5 Exclusion Criteria for Radiofrequency
Exclusion criteria related to the use of mono- or bipolar RF
are recent treatments with oral retinoid (at least for 6 months)
and botulinum toxin (3 days after infiltration); infiltration of
absorbable fillers, photo-rejuvenation, chemical peels,
microdermabrasion, skin resurfacing, or facelift (at least for
6 months); infiltration of permanent fillers (forever); preg-
nant women; patients with pacemakers; immunodeficiency,
and collagen and vascular diseases [23].
1.6 Complications: Risk Assessment
The formation of scars is considered the main risk related to
the RF treatments. In general, the incidence of complications
is extremely low and is around 1 % of the cases [18–20, 24].
Inflammation of platysma muscle may occur especially
after high-energy (>115 kJ/cm2) applications. Burns of the
skin, even with the use of a cooling system, are possible events
and could be related to an incorrect contact of the electrodes to
the system (ThermaCoolTM, Thermage Inc., Hayward, USA)
with the skin which acts as an arc for the monopolar RF [25].
Basically, the risk of side effects and complications is related
to the experience of the operator. General recommendations
are the same suggested when using laser therapy. Specific rec-
ommendations for RF are to reduce energy emission in areas
1160 L.A. Dessy

a b

c d

Fig. 4 Clinical case of a patient treated with Aluma every 2 weeks (8 sessions in total). On the left, pretreatment aspect; on the right, after 2
months from the treatment end

in proximity of the underlying bones (cheeks, chin, temples,
forehead), to degrease carefully the skin before the treatment,
to apply the right quantity of couplant gel, and to properly
position the applicator with a constant pressure in order to pre-
vent the release of incostant energy [19, 20]. Moreover, it is
important to prepare the patient before the procedure, by
removing metal objects that may alter the impedance tissue.
The patient should be properly informed about the benefits
and risks of treatment and sign a consent form according to the
laws. Finally, the operator should always take standard pic-
tures of the area of interest, before and after the treatment, in
order to collect a useful documentation of each patient (Fig. 4).
procedures or colonoscopy. Carbon dioxide has many applica-
tions; it can be used either for the treatment of cellulite or in
medicine and aesthetic surgery [26–30]. For example, the use of
carboxytherapy is described for the cosmetic treatment of
stretch marks and recent scars. Fresh and postpartum red stretch
marks can regress permanently with carbon dioxide, and it can
be also used for the treatment of localized fat and skin irregulari-
ties following liposuction [29, 30]. It is also indicated for face
and neck and décolleté rejuvenation to obtain a brighter and
more tonic skin [31]. It is particularly effective in the eyelid to
reduce dark circles, improve the texture, and brighten the skin.
In addition, the carbon dioxide can also treat skin laxity (loose
skin and sagging) of the abdomen, arms, and legs.

2 Carboxytherapy
Carboxytherapy is a nonsurgical medical and cosmetic treat-
ment that uses carbon dioxide (CO2) in a gaseous state given to
the skin percutaneously or transcutaneously through microin-
jections with 30G needles. It is a safe and not toxic procedure,
with no risk of embolism even if is used in large quantities. In
fact, high doses of CO2 are regularly needed during laparoscopic
2.1 CO2: General Data
CO2 is an odorless and colorless gas. Lavoisier, in the seven-
teenth century, described its functions in respiration, and
almost a century later, Miesher demonstrated its effects and
properties. Together with the water, CO2 is the end product
of the metabolism of organisms.
Noninvasive Physical Treatments in Facial Rejuvenation
The practice of this procedure is not new. In the 1930s, in
Argentina, Dr. DiCio described for the first time the use of
CO2 subcutaneously. In Europe, carboxytherapy has been
practiced since the 1930s especially in the thermal area of
Royat, France. The treatment consisted in the administration
dioxide carbon percutaneously through dry carbogaseous
baths or water dioxide baths (CO2 99.4 %). Thousands of
patients have been treated in the past years, confirming the
therapeutic efficacy and safety of the method. In Italy, car-
bon dioxide has been imported in the early 1990s at the Spa
at Rabbi (TN) that has the same characteristics of the thermal
baths in France. Nevertheless, percutaneous administration
of a gas depends on many variables, such as gas concentra-
tion (1.2–1.4 gr/l), ambient temperature (34 °C), thickness of
the stratum corneum, and blood flow. All these factors, as
well as the presence of an appropriate disposal systems for
large volumes of CO2, limit the use of this therapy only in
spa (thermal baths) environments, influencing hence its
effectiveness.
Currently, the gas is introduced in subcutaneous tissues
(transcutaneously) with the use of a device capable of deliv-
ering CO2 in a controlled manner, with well-defined volumes
and reduced delivery time. This procedure can be performed
in outpatient for a wide range of pathologies such as periph-
eral arterial disease, edematous fibrosclerotic panniculopa-
thy, localized fat deposits, vascular acrosyndromes, and
acrocyanosis.
2.2 Use of CO2 for Therapeutic Purposes
With age, the subcutaneous capillaries become less active,
reducing circulation and limiting the supply of oxygen to the
cells. This process in association with environmental stress
and other variables inhibits cellular functions and ability of
regeneration. The mechanism of action of carboxytherapy is
both chemical and mechanical. CO2 is infiltrated and
delivered directly beneath the surface layer of the skin. The
body perceives the presence of the substance as a lack of
oxygen and reacts by increasing the blood flow. In this way
there is an increase of the oxygen and nutrients at the level of
the treated areas and a consequent general improvement of
cellular metabolism and blood circulation. Furthermore, the
insufflation with CO2 causes the distension of the fibrous
septa that connect the skin to the underlying layers, deter-
mining their rupture and resulting in a dermal reorganiza-
tion. Recent studies have demonstrated the effectiveness of
carbon dioxide in stage II peripheral arterial disease. They
highlighted the positive vasomotor effects through studies
with Doppler and laser-Doppler and reported an increase of
femoral blood flow and pressure of the lower limb [32–34].
The effects of CO2 are characterized not only by the improve-
ment of local parameters of circulation and tissue perfusion,
but also by the increase of the O2 transcutaneous partial pres-
1161
sure [29]. This could be due to hypercapnia that increases
capillary blood flow, to the reduced oxygen consumption at
the level of skin surface, or to the rightward shift of the dis-
sociation curve of O2 (Bohr’s effect) [33].
CO2 effects are expressed on:
• Microcirculation. It mechanically reopens the capillaries
closed, reactivates those malfunctioning, and increases
the percentage of oxygen in the tissues, improving the
state of pathologies such as lower extremity peripheral
arterial disease and various kinds of ulcers.
• Arterioles. It has an active vasodilator effect performed
by the action of CO2 on vascular myocyte and through a
sympatholytic-mediated mechanism.
• Adipose tissue. It breaks the fat cell membranes reducing
the accumulation of fat. In addition, the effects of CO2 on
the adipose tissue can be a direct lipolytic and indirect
lipolytic effect. In the first case there is a mechanical
action mediated by the gas flow that is injected in the
hypodermis (without damaging the other tissues). The
indirect lipolytic effect is related to the ability of the gas
to increase the bioavailability of oxygen (reducing the
affinity of the same for hemoglobin) for metabolic activi-
ties of the adipocytes, including fatty acids oxidative pro-
cesses. Another “fat burning effect” could be caused by
the activation of specific mechanical cutaneous receptors
(Golgi and Pacini corpuscles) and liberation of molecules
(bradykinin, serotonin) that would stimulate numerous
enzyme systems such as the intra-adipocyte lipase, in
order to obtain the hydrolysis of triglycerides.
• Skin. It increases the percentage of oxygen in the tissues
and improves skin elasticity, determining a rejuvenation
of the skin by accelerating the turnover of collagen [31].
In conclusion, carboxytherapy improves the metabolic
functions of a district in situations of microvascular maldis-
tribution and especially optimizes the oxidative enzymatic
degradation of fatty acids, thanks to its vasodilator effect and
increased release of oxygen from hemoglobin
2.3 Transport and Disposal of Carbon
Dioxide
Our body produces approximately 200 ml of CO2 per minute
under basal conditions and 10 times this amount during a
physical exercise.
CO2 spreads rapidly from the cells to the bloodstream, and
then it is transported in the mixed venous blood, under differ-
ent forms (bicarbonate ion and/or combined with the hemo-
globin or other plasma proteins and/or in solution at a voltage
tension of 46 mmHg). It is eliminated in the lungs, where is
exhaled at the same rate as it is produced, leaving in the alve-
oli and in the arterial blood a CO2 pressure of 40 mmHg. The
1162
a b
Fig. 5 Clinical case of a patient treated with carboxytherapy on the lower eyelid once a week (6 sessions in total). On the left, pretreatment aspect;
on the right, after 2 months from the treatment end. The arrows indicate the skin wrinkles before and after treatment
inhalation of CO2 to 2 % stimulates respiration that produces
an increase in the frequency and the depth of ventilation.
There are two areas of stimulation in the trunk brain:
1. Bulbar chemoreceptors
2. Peripheral chemoreceptors
Therefore, the effects of CO2 on the circulation are the
result of a local direct effect plus an immediate effect mediated
by the sympathetic activity of the autonomic nervous system.
1. The direct effect on the blood vessels results in vasodilata-
tion. It has been observed that the subcutaneous injection
of gas CO2 (300 cc) in the forearm produces a significant
increase in the rate of CO2 in venous blood. This phenom-
enon is interpreted as a result of vasodilatation.
2. The indirect effect is determined by activation spread of the
sympathetic nervous system which produces an increased
plasma concentrations of adrenaline, noradrenaline, angio-
tensin, and other peptides. The result is vasoconstriction.
Therefore, the total circulatory response is regulated by
the balance of direct and indirect effects. However, the vaso-
dilator effects seem to have a greater influence than those
mediated by the sympathetic system. The vasodilatation also
affects the cerebral coronary circulation [35].
The overall effect derived by the inhalation of CO2 results
in a reduction of peripheral resistance. Low doses (inhalation)
of CO2 have a depressant effect on the cerebral cortex and
increase the drug-induced seizure threshold. Otherwise, in
higher doses (25–30 %), it has a stimulating effect due to the
activation of subcortical centers and can induce seizures.
L.A. Dessy
2.4 Therapeutic Uses of CO2
Inhaled CO2 is used in anesthesia, in the treatment of hiccups
and sudden deafness [36], and for insufflation in processes
with endoscopic electrocautery [37].
Subcutaneous CO2 is used in the management of cellulitis
syndrome, in localized adiposity.
Cellulitis syndrome is not a simple cosmetic concern but
the expression of various pathological processes that must be
investigated as any other pathology [38].
This syndrome plays a fundamental pathogenetic role for
the alteration of the microcirculation that can manifest with
“microvascular stasis and regressive biotrophism” [38].
Considering the microvascular action of CO2 and the
microangiopathic pathogenesis of cellulitis syndrome, it is
easy to understand the scientific rationale behind the use of
carboxytherapy in the treatment of this disease. Localized
fat is an aesthetic problem and is almost always associated
with a cellulitis syndrome. Nevertheless, it does not pres-
ent histomorphological and microvascular alterations
(microangiopathic stasis), characterized by aggregation of
adiposity and fibrosis. From a microcirculatory point of
view, the presence of avascular zones is due to the com-
pression of the adipose tissue on the capillaries, with no
evidence of stasis. This situation may be associated with
lipedema and appearance of lymphedema and evolved
toward the liposclerosis and, therefore, toward clinical evi-
dences of “cellulitis syndrome.” The use of the carboxy-
therapy in case of localized adiposities is based on the
increase of the flow speed in the precapillary arterioles that
promotes lipolysis with reduction of the lipogenesis
(Fig. 5).
Noninvasive Physical Treatments in Facial Rejuvenation
2.5 Treatment for Facial Rejuvenation
The main targets of carbon dioxide in facial rejuvenation are
facial tissue oxygenation, tonification of the saggy skin, and
brightening and firming up the eyelids and eye contour. It is pos-
sible to treat the eyelids, lips, and neck (Fig. 6). At the level of
the eyelids region, three injections for each eyelid are enough to
get the correct gas insufflation. It is a medical treatment that can
be done with microinjections performed with microneedles
(30G), only by a trained medical staff. It is an outpatient treat-
ment. The percentages or concentrations of CO2 are evaluated
by a clinician and may vary depending on the skin type, the type
of clinical evidence, or disease treated. Usually, there is one ses-
sion at week. The number of sessions, which usually includes a
a The beneficial effects of massotherapy on the skin and sub-
b
Fig. 6 Clinical case of a patient treated with carboxytherapy on lips
once a week (7 sessions in total). Above, pretreatment aspect; below,
after 2 months from the treatment end. The arrows indicate the skin
wrinkles before and after treatment
CO2 insufflation Fibrous septa rupture
Fig. 7 Schematic drawing showing treatment phases of carboxytherapy; above, insufflation phase; center, fibrous septa rupture; below, dermal
regeneration
1163
cycle of treatment, varies from 5 to 6 up to 12–15 depending on
the pathology to be treated. The duration of each treatment may
range from 5 to 15–20 min. The return to normal activities is
immediate. The treatment cycles may be repeated 2 or 3 times
at year. Most of the people who underwent carboxytherapy
notice an improvement after the first treatment, although it usu-
ally takes up to 1 month for the body to react to the process. Side
effects are represented by moderate local pain, a slight crackling
under the skin, and feeling of heaviness and swelling of the
treated area. All these manifestations can last from a few min-
utes up to 24–48 h after the procedure (Fig. 7).
3 Massotherapy
cutaneous tissues had been known since the ancient times.
Nowadays, there are many fields of applications, and this
medical therapy can be performed for physiotherapeutic and
aesthetic purposes. The effect that is obtained with a correct
massage is basically the lymph drainage. The aim of the
lymph drainage is to find alternative routes to help drain the
lymph to other areas of the lymphatic system in patients who
suffered a local traumatic event. The purpose of this type of
massage is to accelerate the elimination of stagnant edema
from a damaged area through slow and regular pressure and
vacuum not exceeding 30–40 mmHg, performed with fingers
or machines along the route of lymph. Removal of the edema
means faster elimination of catabolic products in order to
facilitate healing processes and improve circulation and
increase tissue oxygenation. You also have an analgesic
effect with a positive action on the autonomic nervous sys-
tem, in particular on the parasympathetic nervous system,
thus producing an inhibition of muscle tone and better tro-
pism of the tissues.
3.1 Manual Massage of the Face and Neck
A correct and effective lymphatic drainage should be per-
formed applying an adequate pressure through several
maneuvers while respecting the direction of the lymph flow
Dermal rejeneration
1164
Fig. 8 Schematic drawing
showing the mechanism of action
of mechanic massotherapy
toward the lymph node stations. The operator should always
begin the treatment with a slight maneuver of pumping of the
lymphatic stations proximal to the treatment area, in order to
empty them according to the principle of “discharge open-
ing” (especially in the face district and neck). Afterwards,
the pressure maneuvers try to drain the area proximal to the
lymphatic stations to make space for liquids that subse-
quently will flow from the distal areas.
For the treatment of the neck and face, we start with
maneuvers of slight pressure from the chest to the shoulders,
neck, and under the chin. Then, keep on draining the man-
dibular line, starting from the chin and advancing toward the
angulus. The drainage direction follows the line extending
from the central area of the upper lip to the parotid gland,
passing under the cheekbones. We proceed by performing
semicircle movements with our fingertips, from the tip of the
nose and the middle of the wing to the base and then draining
the bottom orbital margin and then scrolling to the mandibu-
lar border. The procedure keeps on with the drainage of the
base of the eyebrow toward the lateral end with slight move-
ments of pumping. The frontal area is drained with a light
pressure toward the center and the side, and then the scalp is
manipulated with pressure toward the frontal, the top, and
the temporoparietal region.
Finally, we reach the side lymphatic chain of the face
which runs from the temple to the mandibular angle.
Manual lymph drainage can be performed in the fourth day
after surgery for 15–20 sessions with a daily frequency and
then every other day until resolution. All the maneuvers car-
ried out in a loose tissue must be performed with a slight pres-
sure and release in order to avoid stretching of the skin. On this
type of skin, after complete healing, it can be made several
treatments with the purpose to regain elasticity. Those treat-
L.A. Dessy
ments aim to massage and mobilize the tissue and stimulate
the blood supply to fibroblasts to induce the production of col-
lagen and elastin. This type of massage can be operated manu-
ally, as well as with the use of mechanical devices that can
perform fast and standardized massages (Lift6®, Icoone®).
3.2 Mechanical Massage
The automated massage is a noninvasive technique for the
mechanical massage of the cutaneous and subcutaneous tis-
sues, based on the application of positive and negative pres-
sures generated by devices consisting of rotating rollers
controlled by a computerized system. In literature, there are
numerous studies on these mechanical devices that evaluate
their efficacy and modifications on tissues, as well as changes
in blood and lymphatic flow at the level of the skin. Encouraging
results have been observed in the treatment of localized and
widespread adipose deposits, in body contouring but also on
retracting scars and rehabilitation for muscular stress.
The action of these computerized devices is mediated by a
dual action of suction-traction which allows to fold a specific
area of the skin. The rollers run on the skin and perform a trac-
tion and at the same time a continuous and/or intermittent suc-
tion that produce a stimulation by negative pressure on the
tissues (Fig. 8). In this way, there is a true mobilization of the
skin and subcutaneous tissue. The whole architecture is
dynamized by the action of the mobile device that stimulates the
arteriovenous microcirculation and lymphatic circulation and
acts on fibroblast and interstitial and adipocyte metabolism.
The main actions are a raised elastic tone, an increased
cellular oxygenation, the reactivation of fibroblast with neo-
synthesis of oriented collagen and elastic fibers and the
Noninvasive Physical Treatments in Facial Rejuvenation 1165

a b

c d

Fig. 9 Clinical case of a patient affected by marked skin laxity of the face and neck treated with mechanic massotherapy with Lift6® twice a week
(15 sessions in total). On the left, pretreatment aspect; on the right, after 2 months from the treatment end

reduction of fibrosis. It also has a circulatory effect, related
to the activation of the capillary system, the reactivation of
vascular tissue trade and the increase of blood and lymphatic
flow. Finally, patients get a neurosensory effect, with physi-
cal and mental well-being.
Immunohistochemical analysis has also reported a better
vascularization proven by an increase of the number of fibro-
blasts and dilated and tortuous blood vessels. It has been
demonstrated that the mechanical forces alter the normal
phenotype of fibroblasts in “secreting phenotypes,” able to
produce collagen, to inhibit the proteases, and to release dif-
ferent types of interleukins [39].
An increase between 27 and 130 % of collagen demon-
strates the action of massotherapy on the tissues [40]. In fact,
the mass of collagen fibers increases along with the number of
treatments, and the epidermis appears to be thicker and more
trophic. Mechanical massage also produces a harmonious
reorganization of the tissue architecture under the skin with a
restructuring of the dermal-epidermal junctions and reappear-
ance of the friction ridges. The result is a more youthful aspect
of the skin [41]. Circulatory action is demonstrated by a very
clear enhancement of skin blood perfusion [42].
Furthermore, we observe an increase of lymphatic flow
(measured with lymphoscintigraphy examination with dis-
persion of radioactive markers) up to three times greater for
more than 3 h after the treatment.
3.3 Applications in Facial Rejuvenation
Recently, several mechanical devices have been developed for the
specific treatment of the face, with the aim of restoring tone to the
tissues and slow down the aging process of the skin. These treat-
ments are suitable for those patients who are affected by mild to
severe facial skin sagging or for those with postoperative sequelae
(scars, edema, and lymphatic stasis), such as those arising in rhyt-
idectomy. The mechanism exploits handpieces specifically
designed for the facial tissues, and the treatment requires cycles of
15–20 sessions, lasting about 15 min, 2–3 times a week. It has
good cosmetic outcomes, and patient satisfaction is high (Fig. 9).
1166 L.A. Dessy

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39:210–217
 Mechanic Resurfacing, Needling,
Dermoabrasion
and Microdermoabrasion
Nevena Skroza, Ilaria Proietti, Concetta Potenza,
and Luca A. Dessy
1 Introduction
As the demand for less invasive, highly effective cosmetic
procedures grows, new treatment options must be explored
and developed. Today, many patients come searching for a
fairly rapid solution to rejuvenate photoaging, abnormal pig-
mentation or vascularity, textural problems, rhytides and
skin laxity. With the aging process, structural proteins that
give the skin most of its physical properties are progressively
destroyed, while fewer new ones are formed [1]. Skin
becomes lax, and gravitational folds and superficial fine lines
appear. Indeed, whereas collagen and elastin synthesis is
high in infancy, it tends to plateau in young adults [1, 2].
From then on, it constantly decreases with age. When the
balance between protein synthesis and destruction becomes
negative, the process of skin aging begins to appear.
The quest for younger-looking skin has spawned many
different topical techniques, for example, carbon dioxide
(CO2) laser resurfacing and deep peelings, which all share
the same principle of damaging the skin to cause fibrosis
[3–5]. The epidermis is a complex, highly specialized organ
that is our primary protective layer from the environment,
although it is only 0.2 mm thick. These treatments injure the
skin epidermis and its basement membrane to instigate the
natural post-traumatic inflammatory cascade. Subsequently,
the smoothening is due to the deposition of dense scar col-
lagen in the papillary dermis. Histologic examination will
show that the epidermis is thinner than before and that the
rete pegs are generally flattened. The high incidence of com-
plications has made CO2 laser resurfacing less popular than
N. Skroza, MD
Dipartimento di Dermatologia “Daniele Innocenzi”,
Università di Roma “Sapienza”, Rome, Italy
I. Proietti, MD (*) • C. Potenza, MD
U.O.C. di Dermatologia “Daniele Innocenzi”,
Università di Roma “Sapienza”, “Polo Pontino”, Rome, Italy
e-mail: ilariaproietti@virgilio.it
L.A. Dessy, MD
U.O.C. di Chirurgia Plastica, Dipartimento di Chirurgia,
Università di Roma “Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_80
it was several years ago. Newer treatments have tried to pre-
serve the epidermis completely (e.g. radiofrequency tissue
heating) or partially (e.g. fractionated laser ablation), which
cause necrosis of cells in the dermis [6–8]. The necrosis is
the stimulus for fibrosis.
An alternative to laser treatments is the use of skin nee-
dling, which protects the epidermis and stimulates natural
collagen synthesis [4]. Orentreich and Orentreich [9] and
Fernandes [10] independently described subcision or dermal
needling by pricking the skin with a needle to scarify the
dermis and build up connective tissue under scars and wrin-
kles. This technique, however, could not be used on large
body surface areas. Camirand and Doucet [11] used a tattoo
pistol to treat scars with ‘needle abrasion’. Although this
technique can be used on larger areas, it is slow and labori-
ous. The fundamental similarity of these different techniques
is that the needles break old collagen structures that connect
the scar with the upper dermis. The trauma induces the
inflammatory cascade, scar collagen is broken down, and
new collagen is replaced once again under the epidermis.
The key to this is the induction of new collagen and elastin
synthesis by the fibroblasts. We have learned in recent years
that transforming growth factor (TGF)-β plays an enormous
role in the first 48 h of scar formation. Whereas TGF-β1 and
TGF-β2 promote scar collagen, TGF-β3 seems to promote
regeneration and scarless wound healing with a normal col-
lagen lattice [12, 13]. The ideal treatment of wrinkles and
scars should be to promote regeneration rather than
cicatrisation.
Based on these principles, Fernandes [14, 15] developed a
new technology, the percutaneous collagen induction (PCI).
This is a simple technique, and with the right tool, it becomes
easy and fast to puncture any skin thoroughly. Percutaneous
collagen induction creates thousands of microclefts through
the epidermis into the papillary dermis. These tiny wounds in
the papillary dermis create a virtually confluent zone of
superficial bleeding that is a powerful stimulus to initiate the
normal process of wound healing. Because it is nonablative,
percutaneous collagen induction can be performed on the
face and body, on all skin types, without concern for aesthetic
1167
1168
Fig. 1 Image of device (Dermaroller®)
unit boundaries, and, very importantly, without predisposing
the patient to hyperpigmentation. For percutaneous collagen
induction, we have used the Dermaroller®, which is a sterile
plastic cylinder with needles protruding between 0.5 and
1.5 mm from the surface to roll vigorously over the skin
(Fig. 1).
Although one treatment may not give the smoothening
seen with laser resurfacing, the epidermis is virtually normal,
and if the result is not sufficient, it can be repeated. The tech-
nique can be used on areas that are not suitable for peeling or
laser resurfacing.
2 Why PCI Works
Percutaneous collagen induction results from the natural
response to wounding the skin, although the wound is minute
(Fig. 2). A single needle prick through the skin would cause
an invisible response. A completely different picture emerges
when thousands or tens of thousands of fine pricks are placed
close to each other.
When a needle penetrates into the skin, the injury causes
localized damage and minor bleeding by rupturing fine blood
vessels. A completely different picture emerges when thou-
sands of fine pricks are placed close to each other. Most
authors consider that skin needling induces a normal wound
healing developing in three phases (Figs. 3 and 4).
The inflammation phase (phase 1) starts soon after the injury:
It is characterized by bleeding (even slight), the release of plate-
lets and the ingress of neutrophils associated with inflammation.
N. Skroza et al.
Microneedle
Channels produced
by microneedle
1
Intact epidermis
Induced collagen
2
Thickened epidermis
New collagen layer
3
Fig. 2 How Dermaroller® works
These cells release growth factors such as TGF-α, TGF-β, plate-
let-derived growth factor, connective tissue-activating protein
III and connective tissue growth factor. These growth factors
alter the activity of keratinocytes and fibroblasts.
During the proliferation phase (phase 2) [16], neutrophils
are replaced by monocytes that change into macrophages and
release several growth factors including PDGF, FGF, TGF-
beta and TGF-alpha, which stimulate the migration and pro-
liferation of fibroblasts. Keratinocytes then become mobile to
cover the gap in the basement membrane. They start produc-
ing all the components to re-establish the basement mem-
brane with laminin and collagen types IV and VII. A day or
two after PCI, the keratinocytes begin to proliferate and
release growth factors to promote collagen deposition by the
fibroblasts. Fibroblasts secrete insulin-like growth factor,
Tissue remodeling (phase 3) [16] continues for months
after the injury and is mainly done by the fibroblasts: colla-
gen type III is laid down in the upper dermis and is gradually
replaced by collagen type I. The matrix metalloproteinases
(MMPs 1-2-3) are essential for the conversion process [17].
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion 1169

Fig. 3 Skin needling induces a

normal wound healing Needling
developing Reepithelisation
TGF-α
Epidermis thinning
Bleeding
TGF-β Fibroblast recruitment
Matrix production

Platelets Peptides Proteases inhibition

PDGF Fibroblasts
Fibroplast proliferation

Nap-2 CTAP

Matrix thickening
CTGF

Neutrophils Monocytes

Fig. 4 Inflammatory cascade

Epidermis thickening
EGF

Collagen type III

Keratinocytes Elastin
GAGs
Fibroblast Proteoglycans

Collagen type I

Text
Matrix production
IGF
Angiogenesis

FGF
Peptides
PDGF
Monocyte
TGF-β

TGF-α

When doing the 1.5-mm Dermaroller®, the needles penetrate
about 1.5 into the dermis and automatically initiate a complex
chemical cascade. Platelets instigate the release of various factors
that set up a chain reaction with the eventual production of numer-
ous growth factors. Fibroblasts migrate into the area, and this
surge of activity inevitably leads to the production of more colla-
gen and more elastin. Keratinocytes migrate rapidly across the
minute epidermal defect and then proliferate, so the epidermis
becomes thicker. Because this needling is deeper, it causes more
trauma, and that means that swelling automatically follows.
If the 0.5-mm Dermaroller® device is used for micro nee-
dling, the bleeding is microscopic and entirely within the pap-
illary and upper reticular dermis because the needles only
penetrate about 0.5 mm at most. Because the epidermis is, on
average, 0.2 mm, one can be certain that the injury will be
limited to the upper layers of the dermis. This excites a smaller
inflammatory response, yet the cascade of growth factors still
gets initiated by the release of platelets through the puncturing
of small vessels by micro needling. The possibility exists that
with micro needling one gets a purer stimulus for collagen
1170
synthesis without the heavy inflammatory reaction because
subdermal fat is certainly not damaged at the same time. It is
believed that because the epidermis is intact, this might favour
predominantly TGF-β3 [18] rather than TGF-β1 and -β2,
which are associated with scar collagen deposition.
Transforming growth factor-β3 is implicated in scarless
healing and normal lattice weave collagen deposition.
Percutaneous collagen induction seems to induce normal lat-
tice weave collagen rather than scar collagen, so theoreti-
cally, TGF-β3 may play an important part in this very early
phase. Within 5 days after injury, a fibronectin matrix is laid
down along the axis in which fibroblasts are aligned and
along which collagen will also be laid down. This collagen is
laid down in the upper dermis just below the basal membrane
separating the dermis from the epidermis. Collagen Type III
is the dominant form of collagen in the early wound healing
phase. Tissue remodeling continues for months after the
injury. Collagen Type III is gradually replaced by collagen I
over a period of a year or more [18].
Recently, a new hypothesis has been proposed to explain
the PCI mechanism of action: When CIT is performed using
a high-quality device, the fine micro-needles do not set a
wound in the classical sense. The wound healing process is
cut somewhat short as the body is somehow ‘fooled’ into
believing that an injury has occurred. According to this new
theory, Bioelectricity – also called ‘demarcation current’ –
triggers a cascade of growth factors that stimulate the healing
phase. When micro-needles penetrate the skin, they set fine
wounds. Cells react to this intrusion with a demarcation cur-
rent that is additionally increased by the needles’ own electri-
cal potential. In some findings by Jaffe [19], the membrane of
a living cell has been shown to have a resting electrical poten-
tial of −70 mV. The electrical potential depends highly on the
transport mechanisms. If a single acupuncture needle comes
close to a cell, the inner electrical potential quickly rises to
−100 mV and more. Cell membranes react to the local change
with an electrical potential that creates increased cell activity
and a release of potassium ion, proteins and growth factors.
Independent from the mechanism of action, the final
result is deposition of new collagen in the upper dermis.
This chapter will be devoted to percutaneous collagen
induction (PCI), which can be done to the face and any area
on the body to achieve normal collagen induction without
visible scarring.
3 Techniques in Use
Orentreich and Orentreich [9] described ‘subcision’ as a way
of building up collagen beneath retracted scars and wrinkles.
Fernandes [10] independently and simultaneously used a simi-
lar technique to treat the upper lip by sticking a 15-gauge nee-
dle into the skin and then tunnelling under the wrinkles in
N. Skroza et al.
various directions parallel to the skin surface. The lip wrinkles
were improved in many cases, but the problem was that bleed-
ing caused severe unacceptable bruising, which sometimes
resulted in hard nodules. Camirand and Doucet [11] treated
scars with a tattoo gun to ‘needle abrade’ them, and although
this can be used on extensive areas, it is laboriously slow, and
the holes in the epidermis are too close and too shallow. These
techniques work because the needles break old collagen
strands that tether the bed of the scar in the most superficial
layer of the dermis, promote removal of damaged collagen,
and induce more collagen immediately under the epidermis.
Ideally, we need to get effects in the reticular dermis to stimu-
late the production of collagen and elastin fibres, but we must
also avoid excessive bleeding under the skin. Based on these
principles, a special tool was designed with needles ranging
between 1 and 3 mm by Fernandes [14, 15] to achieve PCI.
3.1 Authors’ Preferred Technique
of Needling
Dermaroller® micro needling (Fig. 1) is a revolutionary way
to stimulate normal collagen production for smoothening
skin and treating fine wrinkles. Medical needling uses 1.5-
mm needles to penetrate deeper into the skin, and this does
cause bruising and swelling. On the other hand, micro nee-
dling uses needles that only penetrate to a maximum of
0.5 mm, and this causes virtually no bruising and minimal
swelling. With micro needling it is possible returning to
work the day after the treatment without any signs except
some pink skin, as though you have been exposed to the sun.
A series of 6 micro needling sessions should be done at inter-
vals ranging from once a week to once a month depending on
the degree of improvement that is required. A major advan-
tage of micro needling is that it can be done for lax skin or
wrinkles of the face, upper lip lines, neck, décolleté, arms,
abdomen, buttocks and legs. It is also useful for shallow acne
scars and stretch marks.
The object of the procedure is to produce thousands of
needle micro lesions through the epidermis into the papillary
dermis. These tiny wounds to the papillary dermis initiate the
normal process of wound healing, which concludes in the
synthesis of collagen Types III and I. This happens in pre-
and postmenopausal females and in men. With the conversion
of collagen Type III into collagen Type I, a tightening of the
collagen lattice occurs naturally. This tightens lax skin and
smoothens out scars and wrinkles. Once the skin has been
prepared with topical vitamins A and C and antioxidants
[20–23] for at least 3 weeks, but preferably for 3 months, one
can go ahead with PCI. If the stratum corneum is thickened
and rough, a series of mild trichloroacetic acid peels (2.5–5 %
trichloroacetic acid in a special gel formulation) will prepare
the skin surface for needling and maximize the result.
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion 1171

a b c

Fig. 5 Needling directions

Fig. 6 Needling procedure

During the first session, each patient was prepared in a

similar manner to surgical procedure: At first, facial skin
was disinfected, then a topical anaesthetic in cream
(Emla®) was applied, leaving it in place for 60 min. Some
patients may demand local or general anaesthesia. The skin
is closely punctured with the special medical needling tool,
consisting of a rolling barrel with needles at regular
intervals.
It comes in a sterile plastic container and is mounted on a
handle at the time of use. Two different needle lengths are
available, that is, 0.5 and 1.5 mm.
Rolling consisted in moving four times in four direc-
tions: horizontally, vertically and diagonally right and left
(Fig. 5). This ensured an even pricking pattern resulting in
about 250–300 pricks per square centimetre. The micro-
needles penetrate through the epidermis but do not remove
it; the epidermis is only punctured and rapidly heals
(Fig. 6). The needles seem to divide cells from each other
rather than cut through them, and thus many cells are
spared. Because the needles are set in a roller, every needle
initially penetrates at an angle and then goes deeper as the
roller turns. Finally, the needle is extracted at a converse
Fig. 7 Feature of the skin immediately after treatment
angle, therefore curving the tracts and reflecting the path of
the needle as it rolls into and then out of the skin for about
1.5 into the dermis. Of course, the skin develops multiple
micro bruises in the dermis, and these will actually initiate
the complex cascade of growth factors that eventually
results in collagen production. The epidermis and particu-
larly the stratum corneum remain ‘intact’ except for the
minute holes, which are about four cells in diameter.
As expected, after the treatment, the skin bleeds for a
short while, but that soon stops. When bleeding stops, there
is serous discharge and is removed from the surface of the
skin using sterile saline solution (Fig. 7). It is essential to use
1172
wet gauze swabs to soak up any ooze of serum when 1.5-mm
needles have been used. If 1.5-mm needling has been done,
the patient should be warned that he/she will look terribly
red and bruised and become quite swollen. The patient is
encouraged to shower within a few hours of the procedure
when back home.
If the skin has been needled with the 1-mm roller, the
bleeding under the skin is microscopic. If 0.5-mm needling
has been done, the patient will only experience a flushed
appearance of the skin and will not develop bruises or
swelling.
4 Indications to the Use of PCI
4.1 0.5-mm Dermaroller (Figs. 8 and 9)
• It can be used to restore skin tightness in the early stages
of facial aging. This is a relatively minor procedure and
can safely be recommended. Some patients who are wor-
ried about surgery may be satisfied with simple PCI. The
arms, abdomen, thighs and buttocks can also be treated. A
course of six treatments is suggested.
Fig. 8 Acne scarring before treatment
Fig. 9 Acne scarring after 12 weeks
N. Skroza et al.
• Fine wrinkles are an excellent indication for needling of
the skin.
• It is an alternative to dermabrasion for mild to moderate
acne scarring.
• It can tighten skin after liposuction. Needling can be done
immediately before or after liposuction and should be
done again at intervals of 1–4 weeks for a minimum of 6
treatments.
• Stretch marks
• Scars can be made less obvious by 1-mm needling, and if
the scars are depigmented, one can achieve a better colour
match with the surrounding skin. If one is treating linear
scars, a simple tattoo artist gun can be used to needle
abrade the scar.
4.2 1.5-mm Dermaroller
• Deep acne scars
• Burn scars
• Severe stretch marks
5 Advantages/Disadvantages
5.1 Advantages of PCI
• Percutaneous collagen induction does not damage the
skin.
• Any part of the body may be treated.
• Skin becomes thicker.
• The healing phase is short.
• It is not as expensive as laser resurfacing.
• The skin does not become sun-sensitive.
• It can be done on people who have had laser resurfacing
or those with very thin skin.
• Telangiectasias may disappear.
• It does not require specific plastic-surgical or dermato-
logical skills but can be done by trained medical staff.
• The technique is easy to master with the new tool that has
been specifically designed for the procedure.
• It can even be done with topical anaesthesia.
• Hyperpigmentation has not yet been described in more
than a thousand cases of needling. This should not be a
surprise because tattoos are virtually never hyperpig-
mented even in darker-skinned people. If a problem does
arise with a tattoo, it is due to the pigment used rather than
the technique, even under the most primitive unhygienic
conditions. The authors have never seen hyper- or
hypopigmentation after needling in patients with darker
skin, for example, African, Indian, Malaysian, Chinese
and Mediterranean skin.
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion
5.2 Disadvantages of PCI
• Exposure to blood. With 1-mm needling, the external
bleeding is minimal, but with 3-mm needling, there is
relatively much more bleeding.
• Although we cannot achieve as intense a deposition of
collagen as in CO2 laser resurfacing, we can repeat the
treatment and get even better results that will last just as
long, if not longer.
1173
• Overaggressive needling may cause scarring especially
when using a tattoo gun.
• There is a need for thorough anaesthesia of the skin when
doing 3-mm needling.
• It takes a longer time to see the result than with laser
resurfacing.
• There is unsightly swelling and bruising for first 4 days
when 3-mm needling has been done.
1174 N. Skroza et al.
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion
Pearls and Pitfalls
Preparing the skin
Photoaged skin has to be converted into healthier,
functionally younger skin before PCI. Photoaging is
not only due to the actual UV damage of dermal tis-
sues but is also the result of a chronic deficiency of
vitamin A. The first step toward skin health is to topi-
cally address this deficiency as well as the other anti-
oxidant vitamins C and E and carotenoids, which are
normally lost on exposure to light [24].
1175
Vitamin A, as retinoic acid, is an essential vitamin
(actually a hormone) for skin that expresses its influ-
ence on about 400–1,000 genes of skin cells. In gen-
eral, vitamin A controls proliferation and differentiation
of all the major cells of the epidermis and dermis. It is
essential for rapid healing of the skin and also has been
shown to facilitate collagen and glycosaminoglycans
production by fibroblasts. It may control the release of
transforming growth factor (TGF) β3 in preference to
TGF-β1 and TGF-β2 because in general retinoic acid
1176
seems to favour the development of a lattice-patterned
collagen network rather than the parallel deposition of
scar collagen.
Retinyl esters are the main form of vitamin A [24] in
the skin, and only tiny fractions of vitamin A are found
as retinoic acid. Fortunately, retinyl esters are easily
and rapidly converted into retinoic acid at physiologic
doses. Retinyl esters do not irritate skin cells, whereas
retinoic acid and retinol are cellular irritants and are
less well tolerated. For that reason, we have chosen to
use products with high levels of retinyl esters. One can-
not understate the value of vitamin A in a rejuvenation
programme for skin. Vitamin A is utterly essential for
the normal physiology of skin and for collagen preser-
vation, but it is destroyed by exposure to light. Adequate
nourishment of the skin with vitamin A (not necessarily
as retinoic acid but rather as retinyl esters, retinol, or
retinaldehyde) will ensure that the metabolic processes
for collagen production will be maximized, and the
skin will heal as rapidly as possible. Vitamin C is simi-
larly important for collagen formation and is destroyed
by exposure to blue light. These vitamins need to be
replaced every day so that the natural protection and
repair of DNA can be maintained. As a result, the skin
will take on a more youthful appearance. The addition
of palmitoyl pentapeptide and/or other similar peptides
will also ensure that better collagen will be formed.
These chemicals, however, cannot achieve really youth-
ful skin because the collagen immediately below the
epidermis has been destroyed by years of sun exposure,
and we need to stimulate the production of collagen in
this area by a more targeted technique. Vitamin C is
also essential for the production of normal collagen.
The demand for vitamin C increases when more colla-
gen is produced, for example, immediately after an
operation. In this particular regard, needling focuses on
creating more collagen, and therefore, it is mandatory
to supply increased levels of vitamin C in the diet and
topically. Ascorbic acid [25] is not well absorbed into
the skin and is also irritant to skin. On the other hand,
ascorbyl tetraisopalmitate has been shown to be the
most efficient form of vitamin C. It easily penetrates
the skin and is also incorporated into skin cells, whereas
ascorbic acid enters the cells with difficulty.
Once the ascorbyl tetraisopalmitate [25] is inside
the cell, it is desterilised and becomes bioavailable as
ascorbic acid.
Care of the skin after PCI
Immediately after a 1.5-mm needling, the skin
looks bruised, bleeding is minimal and serum oozes
for a time after the bleeding stops. The patient is
N. Skroza et al.
encouraged to use topical vitamin A and vitamin C
cream or oils to promote better healing and greater
production of collagen. The addition of peptides such
as palmitoyl pentapeptide could possibly ensure even
better results. The skin feels tight and might look
uncomfortable, but it is not. The next day, the skin
looks less dramatic, and by day 4–5, the skin has
returned to a moderate pink flush that can be concealed
with make-up. Some residual bruising may still be
present. Iontophoresis and sonophoresis of vitamins A
and C will maximize the induction of healthy collagen
and can be done the day after 1.5-mm needling.
Iontophoresis also tends to reduce the swelling of the
skin. Low-frequency sonophoresis can be used to
enhance penetration of palmitoyl pentapeptide or other
peptides.
Our experience has shown that ascorbic acid is not
safe to use on skin immediately after needling because
it can cause superficial necrosis (peeling). If 0.5-mm
needling has been done, the skin is treated as normal
skin, and the patients should use their normal skin care
regimen with high-dose vitamin A (preferably as reti-
nyl esters) and vitamin C.
6 Dermoabrasion
6.1 Introduction
Dermoabrasion is a surgical procedure, the aim of which is
to soften skin surface irregularities or to mask scars through
the mechanical removal of the superficial layer of the skin
and by giving it a more regular and smooth appearance.
Modern rejuvenation techniques are nothing more than a
reminiscence of ancient ones. In fact, the first description of
dermoabrasion dates back to 1500 B.C., by the Egyptians
who describe the use of sandpaper to smooth out scars. As
the time passed, different cultures developed several tech-
niques of skin rejuvenation with evidence in the Old
Testament, in Roman times and in the years ahead. In the
ninth century, Arabic doctors prepared a special facial mask
made of fragments of rice, shells, marble, crystals, lemon,
eggs, beans and lentils, which was wrapped on the face in
order to produce a superficial dermoabrasion. At the begin-
ning of the twentieth century, the scientific community
started to reuse rejuvenation techniques, and in 1905,
Kromayer became the first one to perform mechanical der-
moabrasion with cutters and rasps [26]. Despite the success
of the procedure, dermoabrasion did not become popular till
the beginning of the 1950s, when Kutrin renewed the interest
for this surgical technique [27].
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion
With the introduction of chemical dermoabrasion (peel-
ing), and starting from the 1990s, of laser resurfacing,
which had become one of the most used procedures for
facial rejuvenation, dermoabrasion lost its popularity due
to doubts on its safety and efficiency compared to other
techniques [28].
Many studies have however demonstrated dermoabrasion
as a safe and effective method for facial rejuvenation and it
should represent an obligatory part of the available equip-
ment for aged and damaged skin resurfacing [29]. It shows,
indeed, characteristics that may make it preferable to chemi-
cal peelings and laser, including the possibility to be used on
restricted areas of the face, the lower cost compared to laser
and the reduced capacity of damaging melanocytes and
cause dicolourations.
The most appropriate choice of the rejuvenation tech-
nique depends on the degree of skin damage that can be eas-
ily quantified by the classification of photoaging of Golgau
[30]. This system classifies the severity of photoaging based
on the degree of epidermal and dermal degeneration from I
to IV. Grade I is characterized by a minimal photoaging.
Patient shows a slight and early photoaging, with few wrin-
kles, which is often treated with dermoabrasion or superficial
chemical peelings. Grade II is characterized by a deeper
level of photoaging which shows wrinkles during facial
expressions. These patients have a mild to moderate photo-
aging and require medium to deep chemical peelings. Grade
III presents wrinkles at rest and they also require medium to
deep chemical peelings. Grade IV shows diffuse wrinkles
with skin discoloration and requires deeper peels or resurfac-
ing procedures associated with a surgical procedure to allow
a significant rejuvenation.
6.2 Preoperative Evaluation
It is necessary to give an adequate history and physical
examination together with the pre-operative photographs. It
is important to evaluate the presence of active lesions of her-
pes simplex or their previous event. In cases of positive his-
tory, drug prophylaxis with high doses of antiviral is
recommended. One tablet of acyclovir 400 mg taken 3 times
a day, to start before treatment and to continue for a few
days after, helps to prevent the onset of the herpetic
infection.
We need to investigate the possible use of drugs, and in
particular, the recent exposure to isotretinoin which is a rela-
tive contraindication to dermoabrasion [31]. It is advisable to
wait for at least 6 months after the end of the therapy with
this drug before proceeding with dermabrasion. The use of
other drugs, such as oestrogen, oral contraceptives or other
photo-sensitizing substances, may predispose hyperpigmen-
tation after dermabrasion.
1177
In addition, it is necessary to investigate the presence of
infectious diseases transferable with blood contact, such as
HIV and hepatitis C. Dermabrasion produces a bloody field
with the formation of aerosol microparticles containing
blood. The risk of transmission of such diseases cannot be
eliminated even using appropriate protective equipment.
Therefore, this procedure is not recommended in these
patients and it would be better to use other methods of
resurfacing.
We need to assess the skin phototype according to the
classification of Fitzpatrick [32]. In general, phototypes I
and II are less likely to heal with changes of skin pigmenta-
tion. The presence of pre-existing dyschromia must be docu-
mented. Although dermabrasion may cause minimal changes
in skin pigmentation, a suitable selection of patients mini-
mizes this complication.
We must also consider the tendency to develop pathologi-
cal scars, the presence of psoriasis, lichen planus, pyoderma
gangrenosum. In these circumstances, it is appropriate to
make a spot test.
Finally, we must consider the reasons and the actual
expectation of the patient before the intervention. Generally,
we obtain a partial improvement and more treatment ses-
sions may be required possibly associated with other resur-
facing procedures. Patients should be informed of the
possible risk of scarring and pigmentation alterations.
The most common indication to dermabrasion are scar-
ring from acne, but it can be used for the improvement of
post-traumatic and surgical scars, asphalt tattoos, photoag-
ing, actinic keratoses, rhinophyma, perioral and, in general,
facial wrinkles, facial hyperpigmentation post-inflammatory
[29, 33].
Acne scars appear to be punctate, with projected and net
margins, and are the most likely to improve after dermabra-
sion (Figs. 10 and 11). Some of these scars can deepen until
they reach the subcutaneous tissue. Dermabrasion can reach
reticular dermis, with the possibility of complete re-
epithelialization, especially in the face, considering the
abundance of skin appendages. Beyond this level, there is a
significant risk of developing new scars. Therefore, deep
scars can be removed first with a punch biopsy, with or with-
out skin micrografting, and subsequently treated with
dermabrasion.
Dermabrasion can also be used for the treatment of rhino-
phyma, a pathology characterized by swelling and redness of
the nose caused by hyperplasia of the sebaceous glands and
by an accentuated skin vascularization [34]. In this condi-
tion, often thickening of the skin occurs, especially at the tip
and wings of the nose. With dermabrasion, it is possible to
obtain an improvement of this condition without applying a
full-thickness skin graft. Re-epithelialization occurs quickly
within a few days. The procedure can be completed by elec-
trocoagulation or by a laser resurfacing.
1178 N. Skroza et al.

Fig. 10 Schematic drawing of a

patient affected by acne scars,
a b
before (on the left) and after (on
the right) dermabrasion

Fig. 11 Clinical case of a

a b
patient affected by acne scars. On
the left, pre-treatment aspect; on
the right, 1 year after
dermabrasion

6.3 Treatment
The surgery is performed under general or local anaesthesia,
or analgesia. If dermabrasion is carried out on the patient’s
face, the surgeon usually acts, not only treating the affected
area, but the entire aesthetic unit in which it is located.
The mechanical removal of the surface layers of the skin
can be performed with steel brushes, scouring pads or with
specific machinery with electric or pneumatic motor,
equipped with a specific handpiece on whose apex are
mounted abrasive tips of various form and composition, able
to rotate at high speed (Fig. 12). Initially, the abrasive tips
were composed of aluminium oxide, or crystals of sodium
bicarbonate, but then they were replaced by diamond drill
bits, in order to increase the accuracy of the procedure, and
reduce irritation.
The areas to be treated are levelled under the action of
milling cutters, put on the skin with gentle pressure, which
rotating quickly wear away the most superficial layers
(Fig. 12). Partial thickness wounds that heal, by epitheliali-
zation, within 7–10 days, are then created, to reduce scars
and skin wrinkles. There is typically a small punctiform
bleeding which stops with adequate postoperative care. The
skin tends to exude for the first 10–12 days, but this process
stops when integrity of the skin is re-established. The com-
plete healing occurs in 2–3 weeks [35].
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion
Fig. 12 Schematic drawing of the handpiece of a dermabrasion instru-
ment on which is positioned an abrasive tip able to mechanically
remove superficial skin layers
At the end of the intervention, gauze soaked in saline
solution are applied on the treated areas, and changed every
hour during the first 24 h post-operatively. The presence of a
yellow secretion on the abraded areas could be noticed dur-
ing this phase, which is to be considered normal.
After the surgery, there is a certain degree of oedema that
may be significant especially if the abrasion was performed
around eyes and lips; this oedema reaches the maximum the
second and third day after surgery, to slowly disappear within
a week. During the first night after surgery, the patient may
feel a slight stinging or pulsating pain, easily controllable
with mild analgesics. After the first 24 h, the treated areas
should be washed every 4 or 5 h, with spring water at body
temperature, and after each wash, plenty of cream with vita-
min ‘A’ and ‘E’ should be applied. This procedure must be
performed for 10 days. During this period, the treated areas
are covered again by new epithelium.
Depending on the importance of the clinical case and on
the surgeon’s habits, the patient can go back home few hours
after surgery. All the postoperative procedures described, can
be performed at home.
If the dermabrasion has been performed on a limited area,
just a modestly compressive dressing to leave undisturbed
for a week, might be sufficient. Treated areas, once healed,
will appear of a rosy intense coloration, and that will persist
for a period ranging from 8 weeks to a few months.
In the first 2 months, the presence of small whitish gran-
ules on the skin, that generally disappear without any treat-
ment, may be observed. The texture of the skin of the treated
areas may differ from that of the untreated ones, making nec-
essary to use a makeup to hide the differences. Furthermore,
1179
for the first 6 months after surgery, the skin must be protected
from sunrays using sunblock creams.
6.4 Contraindications
As already mentioned, taking isotretinoin is a relative contrain-
dication to dermabrasion. Such drug causes atrophy of the pilo-
sebaceous glands, delaying re-epithelialization and increasing
the risk of hypertrophic scarring [31]. It is advisable to wait
6–12 months before proceeding with dermabrasion.
Dermabrasion can also exacerbate certain dermatological
chronic conditions, such as scleroderma, cutis laxa, psoria-
sis, congenital ectodermal dysplasia and collagen diseases
characterized by the development of abnormal adnexal struc-
tures, promoting even in these cases, delayed re-
epithelialization with risk of pathological scarring.
Dermabrasion is contraindicated after recent surgery that
required a dissection of the skin, such as a face lift. It is rec-
ommended to postpone dermabrasion at least 6 months, to
allow the re-establishment of vascular connections between
the skin and the deep layers.
Even prior radiotherapy is a relative contraindication to
treatment because the skin presents itself thinned.
Coagulopathy, immunosuppression and diabetes mellitus
may delay the healing process and increase the risk of infec-
tion. These conditions are relative contraindications too.
Deep wrinkles and the excess of skin are not indicated for
this type of treatment.
At last, dermabrasion is contraindicated in the case of
pathological healing, HIV infection, herpes active lesions, in
pregnant women or in those who are breast feeding.
7 Microdermabrasion
7.1 Introduction
Microdermabrasion is a variation of dermabrasion, which
produces a more superficial and more delicate removal of the
skin layers, thanks to the emission of high-speed jets of air
and water, possibly associated with microcrystals made of
aluminium oxide [36].
Microdermabrasion is intended to smooth the skin. It
eliminates the outer layers of the epidermis (stratum cor-
neum and Malpighian layer) without damaging the architec-
tural structure of the skin, keeping the dermo-epidermal
junction intact, with minimum risks of bleeding and de-
epithelialization, typical of the normal techniques of derm-
abrasion. It is also less or not effective at all for the treatment
of wrinkles and deep scars. Among the advantages that make
this method well accepted by the patients are that it is pain-
less, does not require anaesthesia and can be repeated after
1180 N. Skroza et al.

short periods of time (5–7 days). Patients who require mul-
tiple treatments, presenting early signs of photoaging are
indicated for this type of light procedure. If the patient does
not want to preside over multiple treatment sessions, the
result would not be significant.
The same method, as needed, can be also used for the
classic dermabrasion, insisting in the same point, with the jet
emitted from the hand piece, until we reach a bleeding layer.
7.3 Treatment

7.2 Mechanism of Action This technique is performed by medical and paramedical

staff, and it is currently being used with great success on
It is currently commercially available in a wide variety of superficial wrinkles, small acne scars, dull skin or other
microdermoabrasion systems. Each includes a pump that irregularities of the skin surface (Figs. 14, 15 and 16). The
generates, from a hand piece, a single jet of air and water and
possibly of microcrystals of aluminium oxide at high speed,
up to 200 m/s (Fig. 13).
The intense rubbing during treatment causes a rise in the
skin temperature of about 5–8°. It is theorized that the repeti-
tive intraepidermal damage produces fibroblast proliferation
and collagen production in the treated areas, resulting in an
improvement of the appearance of wrinkles [36].
Generally, two treatments for each session are performed.
These are interspersed with a cleaning of the skin surface, and
having as end point the onset of erythema. Through the rub-
bing on the skin, small parts of it are mechanically excised.
Several clinical studies have shown histologic changes
with an increased vascularity, increased thickness of epider-
mis and dermis associated with a moderate subjective
improvement reported by the patient [37, 38].
This method preserves the biology of the tissues, which
are slightly abraded. Immediately after surgery, creams suit-
able to improve the microcirculation are applied on the treated
skin. The face looks smoother and free of impurities. In some Fig. 13 Photogram of a handpiece of a microdermabrasion instrument,
cases, red areas that disappear within a few hours may remain. the tip of which emits high-speed jets of air and water

Fig. 14 Clinical case of a

patient affected by acne scars. On
the left, pre-treatment aspect; on
the right, 6 months after
microdermabrasion
Mechanic Resurfacing, Needling, Dermoabrasion and Microdermoabrasion 1181

Fig. 15 Clinical case of a

a b
patient affected by signs of skin
photoaging. On the left,
pre-treatment aspect; on the
right, 1 year after
microdermabrasion

Fig. 16 Clinical case of a

a b
patient affected by vertical lip
wrinkles (i.e. bar code). On the
left, pre-treatment aspect; on the
right, 6 months after
microdermabrasion

results obtained with this technique have been called ‘baby
skin’ or skin as a child. A unique treatment that exfoliates
and renews the surface layers of the epidermis and then
allows it to obtain a fresh, smooth and radiant skin.
It is an outpatient, non-invasive, painless and repeatable
over time treatment.
The duration of the treatment varies, on average, from 10
to 20 min, can be performed on all skin types and represents
a valid alternative to chemical peels and classic dermabra-
sion. A single treatment is able to produce appreciable but
not lasting effects. The protocol provides 4–6 sessions to be
repeated with intervals of 15–20 days. It is not normally car-
ried out in summer periods or in anticipation of prolonged
exposure to the sun.
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 Antiaging Cosmeceuticals
Lily Talakoub, Isaac M. Neuhaus, and Siegrid S. Yu
1 Introduction
The Food, Drug, and Cosmetic Act defines drugs as products
that cure, treat, mitigate or prevent disease, or affect the
structure or function of the human body [1]. The dermatol-
ogy and cosmetic industries recognize “cosmeceuticals” as
cosmetics that have drug-like benefits. The term “cosmeceu-
tical” was first used by Dr. Albert Kligman to describe a cos-
metic product that exerts a therapeutic benefit in the
appearance of the skin, but not necessarily a biologic effect
on skin function, which would then classify it as a drug [2–
4]. The Food and Drug Administration does not recognize or
regulate cosmeceuticals. The symbiotic relationship between
a drug and a cosmetic has become increasingly evident with
the rapid growth of the cosmeceutical industry over the last
decade. There are now both prescription cosmeceuticals and
over-the-counter cosmeceuticals available to consumers.
This arbitrary distinction varies in different countries. For
example, drugs such as tretinoin, available only by prescrip-
tion in the United States, are sold as over-the-counter cosme-
ceuticals in Central America. Antiperspirant is also regulated
as a drug in the United States while being considered a cos-
metic in Europe.
The market for cosmeceuticals in the United States has
grown substantially over the last 10 years as the median age
of the population increases and the market for noninvasive
rejuvenation increasingly expands. Skin care companies
often make miraculous claims based on little scientific evi-
dence. In the modern era of direct-to-consumer advertising,
claims can be misleading, causing the false belief that these
products are subject to the same standards and vigorous test-
ing for safety and efficacy as drugs.
Whether in an academic, medical, or surgical dermatol-
ogy setting, many patients and colleagues inquire about these
products. As professionals and leaders in the field of skin
care, dermatologists must develop a solid knowledge base to
inform and educate patients and peers regarding the use of
skin care cosmeceuticals.
This chapter briefly summarizes skin barrier function and
provides an overview of the most common cosmeceuticals
on the US market. As previously alluded to, little scientific
evidence exists for many of the products mentioned. The
best available evidence is reviewed, though many of the pur-
ported benefits highlighted in this chapter are anecdotal.
2 The Skin Barrier
2.1 Key Points
1. The stratum corneum provides the permeability barrier of
the skin.
2. Cholesterol, free fatty acids, and glucosylceramides are
the essential lipids providing the permeability barrier.
3. Genetic and environmental factors alter lipid production
and the skin barrier repair mechanism.
One of the integral roles of the skin is to maintain a bar-
rier between the body and the external environment. Its var-
ied roles include preventing the loss of body fluids and
electrolytes, regulating body temperature, and protecting
against ultraviolet radiation, oxidants and microbes.
Despite the vast advances in basic science and pharmacol-
ogy, limited products and drugs have been developed that
can penetrate this sophisticated, highly organized biologic
membrane [5].
The stratum corneum serves as the permeability barrier of
the skin. Disorders of its maintenance and repair remain
among the leading causes of skin diseases. A measure of bar-
rier integrity is the calculation of transepidermal water loss
(TEWL) [6]. TEWL is an objective measure of water loss
from the skin in g/m2h, excluding losses due to sweating [7].
, 4ALAKOUB -$ s )- .EUHAUS -$ * s 33 9U -$
Department of Dermatology, University of California, San
Francisco, CA, USA
e-mail: isaac.neuhaus@ucsf.edu
Normal daily TEWL in adults ranges between 3.9 and 7.6 g/
m2h. In disorders of cornification or barrier function, such as
ichthyosis or atopic dermatitis, these levels can range above

© Springer Berlin Heidelberg 2016 1183

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_81
1184
15 g/m2h [8, 9]. Studies have shown that the repair mechanism
of the stratum corneum responds to detergents, solvents, and
trauma by increasing the machinery needed for lipid synthe-
sis and secretion to minimize the TEWL [10]. Aging and
UVB radiation are among the many other stressors to the
skin which decrease skin barrier function and increase
TEWL [11].
The stratum corneum is made of keratinocytes embedded
in a structurally and biochemically diverse matrix of parallel
lamellar membranes made of cholesterol, free fatty acids,
and glucosylceramides [12]. The corneocytes form the cohe-
sion of the cornified envelope [13], while the lipid matrix is
the essential element of the stratum corneum’s barrier func-
tion [14]. The barrier repair mechanism relies on the synthe-
sis and regulation of these three components, in equimolar
concentrations which work symbiotically to regenerate new
lamellar bodies [15].
Hydration of the skin is dependent on the corneocyte nat-
ural moisturizing factor (NMF) and the lamellar bodies of
the extracellular matrix [16]. Once the stratum corneum’s
water levels fall below a critical point, as measured as a 1 %
increase in TEWL, the enzymatic function required for des-
quamation is impaired [17]. This results in increased corneo-
cyte adhesion, resulting in the accumulation of scale and the
appearance of dry, flaky skin [18].
Exfoliation of the skin is a tightly controlled mechanism
required for hydration, flexibility, and tissue integrity. A
complex series of enzymatic hydrolytic reactions disrupts
the desmosomal attachments between corneocytes. This
highly controlled mechanism is predominantly regulated by
the pH and water content of the stratum corneum, as well as
the corneocyte-derived natural moisturizing factor (NMF)
made from the hydrolysis of the protein fillagrin. The
homeostasis of the stratum corneum is dependent on many
signaling mechanisms, including water content, pH, cal-
cium levels, and cytokine milieu, all of which promote a
cascade of events leading to exfoliation, barrier repair, and
recovery [19].
Many genetic and environmental factors alter lipid pro-
duction and the skin barrier. Ultraviolet radiation, aging,
atopic dermatitis, oral glucocorticoids, disease, diet, stress,
and humid or dry environments play a role in the perturba-
tion and delayed repair of the epidermal barrier [20]. Studies
also demonstrate racial differences in skin barrier function.
Since repair normally functions at an acidic pH, neutraliza-
tion of this pH delays the normal repair mechanism and
increases the abnormalities in corneocyte adhesion [21].
Successful treatment of these perturbations relies upon the
understanding of the barrier mechanism and the underlying
structural and physiologic mechanisms behind normal, dry,
oily, and so-called “sensitive” skin [22] (Fig. 1).
L. Talakoub et al.
Lipids
Corneocyte
Water
Fig. 1 The skin barrier - bricks and mortar illustration
3 Skin Type
3.1 Key Points
1. Skin type is defined by a balance of re-epithelialization
and desquamation, sebum secretion, and hydration.
2. Skin type can be measured objectively, but is often a sub-
jective assessment of tangible or visible areas of
disequilibrium.
Normal skin is defined as skin with a balance of re-
epithelialization and desquamation, sebum secretion, and
hydration. There are therefore no tangible or visible areas of
disequilibrium. A minority of individuals present with nor-
mal skin type, and normal skin characteristics can easily
change with age, ambient temperature, humidity, and
mechanical or chemical stresses [23]. Oily, greasy, or shiny
skin can be due to an increase in sebum production during
adrenarche, the presence of acne due to a shift in androgen
production, abnormal keratinizatin and P. acnes prolifera-
tion, or seborrhea [24]. Self-perceived dry skin is usually due
to a defect in the barrier function of the stratum corneum
with an increase in TEWL and a subsequent feeling of
chapped, tight, scaly skin [25]. Dry skin is usually a second-
ary manifestation of excessive cleansing, stripping the stra-
tum corneum from natural lipids, UV radiation, exposure to
extreme climates, or treatment with agents such as retinoids.
Sensitive skin has a low threshold for irritancy. Patients with
sensitive skin develop stinging, burning, or widespread der-
matitis from topical applications of products, particularly
those with fragrance, acid or alkaline pH, or preservatives
[26, 27].
Skin type can be assessed with meticulous methods of
measuring TEWL, sebum production, and mathematical
calculations of skin pigment color and elasticity [28].
However, even objective measurements may be an inac-
curate representation of a patient’s self-perceived skin
type.
Antiaging Cosmeceuticals 1185

4 Moisturization the proteolysis of the corneocyte desmosomes, thereby aid-

ing in desquamation [41]. NMF components such as sodium
4.1 Key Points pyrrolidone carboxylic acid, lactate, and urea have also been
shown to decrease TEWL and increase skin capacitance
1. Moisturizers contain lipids and ingredients with emol- (Fig. 3). In particular, moisturizers with urea have been
lient, humectant, and occlusive properties. shown to decrease TEWL in atopic and ichthyotic patients.
2. Selecting an optimal moisturizer depends on the skin
type, vehicle, and the needs of the patient.
Table 2 Moisturizer properties
Moisturizers function to restore the hydration of the epi- Moisturizer property Ingredient
dermal barrier [29]. However, the water within a moisturizer Occlusive Petrolatum
only adds a transient increase in the hydration of the stratum Mineral oil
corneum. Physiologic lipids, when applied together in equi- Paraffin
molar concentrations, enhance the stratum corneum’s own Squalene
lipid synthesis mechanism [30, 31]. Non-physiologic lipids Silicone derivatives (dimethicone and
do not penetrate the stratum corneum, but rather provide bar- cyclomethicone)
rier protection by intercalating between corneocytes creating Lanolin
a diffuse hydrophobic impermeable surface [32]. Neither of Caprylic/capric triglyceride
these lipid categories, when externally applied, retards the Carnauba and candelilla wax
normal production of lipids within the stratum corneum [33]. Lecithin
Cholesterol
Moisturizers available today have different combinations of
Propylene glycol
these physiologic and non-physiologic lipids, as well as
Stearic acid
ingredients with emollient, humectant, and occlusive proper-
Cetyl and stearyl alcohol
ties [34–36] (Tables 1 and 2).
Humectant Glycerin (glycerol)
Occlusives are agents designed to reduce TEWL by reduc- Sodium pyrrolidone carboxylic acid
ing the evaporation of water from the skin by forming a Sodium lactate
hydrophobic film on the skin between the corneocytes. Propylene glycol
Occlusive ingredients are greasy, and function best when Sorbitol
applied to slightly dampened skin. Petrolatum can reduce Ammonium lactate
TEWL by 98% and is the most effective occlusive agent [37, Potassium lactate
38]. Mineral oil and lanolin are also used widely in over-the- Sorbitol
counter skin care products, though they are less efficacious in Urea
preventing TEWL when compared with petrolatum. Mineral Panthenol
oil is the main ingredient excluded in oil-free products. Honey
Lanolin has been implicated in many cases of allergic contact Gelatin
dermatitis. Silicone derivatives are smoother in texture, less Hyaluronic acid
greasy but also have limited ability in preventing TEWL [39]. Emollients Dimethicone and cyclomethicone
Propylene glycol
Humectants attract and trap water from the dermis and the
Glycol stearate
humid environment for the stratum corneum. They can, how-
Glyceryl stearate
ever, paradoxically cause this water to be lost into the envi-
Lanolin
ronment and thus need to be used in conjunction with an
Soy sterol
occlusive agent to prevent further TEWL [40]. The most Sunflower seed oil glycerides
effective humectant, glycerol, binds and holds water in the Octyl dodecanol
stratum corneum, and also minimizes water loss and aids in Hexyl dodecanol
Oleyl alcohol
Oleyl oleate
Table 1 Physiologic and non-physiologic lipids Octyl stearate
Physiologic lipids Non-physiologic lipids PEG-7 glyceryl cocoate
Ceramides Petrolatum Coco caprylate caprate
Cholesterol Bees-wax Myristyl myristrate
Free fatty acids Lanolin Cetearyl isononaoate
Squalene Isopropyl myristate
1186 L. Talakoub et al.

Table 3 Components of the natural moisturizing factor within Table 4 Components of soaps and syndets
corneocytes
Soap Syndet
Components of the natural moisturizing factor (NMF) Sodium cocoyl isethionate Sodium tallowate
Pyrrolidone carboxylic Stearic acid Sodium cocoate
Urea/uric acid Lactate acid (PCA) Chloride Sodium stearate Palm kernelate
Sugars Amino acids Ammonia Calcium Cocamido propyl betaine Sodium palmitate
Sodium Formate Citrate Magnesium Polyethylene glycol (PEG) Water
Glucosamine Creatinine Phosphate Sodium isethionate PEG-6 methyl ether
Coconut fatty acid Palm acid or tallow acid
Emollients are generally lipids and oils, which play a role Natural oils Fragrance
Salts Glycerine
in filling the crevices between desquamating corneocytes,
Sequestrant Sorbitol
thereby causing the appearance of a smooth skin texture,
Titanium dioxide Sodium chloride
enhanced flexibility, and skin softness. Not only do these
Pentasodium pentetate
products provide instant lubrication and moisturization, they
Tetrasodium etidronate
have also been shown to improve barrier repair. These agents Butyl hydroxyl toluene (BHT)
correlate with consumer satisfaction as they provide the Titanium dioxide
instantaneous feel of moisturization (Table 3).
Most moisturizer formulations consist of lotions or creams
with a combination of an occlusive, humectant, and emollient surfactants that lift dirt and aid in the solubility and absorption of
[42]. A lotion is an oil-in-water emulsion, whereas a cream is a oils. Surfactants can be harsh to the proteins and lipids in the stra-
water-in-oil emulsion. Cosmetically elegant lotions have a thin- tum corneum, potentially causing barrier damage and dryness
ner consistency than creams and are often used in day moistur- [40]. New milder cleansers, however, are made to minimize this
izers. These products also contain mineral oil, propylene glycol, damage while providing additional moisturization to the skin.
and water. Creams are thicker and greasier than lotions, and are Soaps were the earliest form of skin cleansers, and are
made of petrolatum or lanolin derivatives, mineral oil, and still widely in use today. New developments in liquid cleans-
water. There are also complicated emulsions consisting of oil- ers and body washes include mild synthetic detergents (syn-
in-water-in-oil emulsions as well as gels, foams, and sprays det), which combine a mild surfactant with a moisturizing
[43]. Emulsion lipids consist of long-chain saturated fatty acids lotion containing a humectant, emollient, and occlusive.
including stearic, linoleic, oleic and lauric acid, found in palm These moisturizing washes contain more emollient than sur-
oil, coconut oil, and wool fat. Other oils used as emollients factant in their list of ingredients, with water being the first
include fish oil, petrolatum, shea butter, and sunflower seed oil. ingredient listed and oils or petrolatum as the second. Thus,
Selecting an optimal moisturizer thus depends on the skin using a cleanser with an emollient provides superior stratum
type, vehicle, and the needs of the patient [44]. For example, corneum moisturization compared to using a soap or mild
dry skin may require a higher oil-to-water concentration and cleanser without an emollient [47].
heavier occlusive agents [45]. On the other hand, oily skin Soaps and syndets generally contain different ingredients and
would benefit from lower oil-to-water ratios and nongreasy differing pH. Syndets are neutral or acidic. In contrast, soaps are
emollients such as silicone, used in combination with oil- alkaline and proven to be more irritating to lipids in the stratum
absorbent compounds such as talc. corneum [48] (Table 4). Studies of patients with atopic dermatitis,
acne, rosacea, retinoid sensitivity and post chemical peel reveal
similar cleansing capabilities of soaps and syndets. However, the
5 Cleansers use of syndets and mild cleansers provides improved skin soft-
ness and reduced irritation compared to soaps [49].
5.1 Key Points

1. Soaps and cleansers contain surfactants that lift dirt and
aid in the solubility and absorption of oils.
2. Mild synthetic detergents (syndets) combine a mild sur-
factant with a moisturizer.
3. Cleansers with emollient properties provide superior stra-
tum corneum moisturization.
Cleansers are products designed to remove debris, make-up,
secretions, sweat, sebum, and bacteria while aiding in the exfolia-
tion of the stratum corneum. Cleansers are formulated with
6 Other Skin Care Products: Masks
and Astringents
6.1 Key Points
1. Masks provide mechanical exfoliation.
2. Toners and astringents are products that are used primar-
ily in antiacne regimens or for antiseptic and antimicro-
bial functions.
3. Toners that are alcohol based can be irritating to the skin.
Antiaging Cosmeceuticals
The skin care market has widely expanded over the last
decade due to the inclusion of skin exfoliating products.
These products often contain numerous other cosmeceutical
ingredients including salicylic acid, vitamins, minerals, and
botanicals.
Masks, originally derived from mud baths, are either
made of polyvinyl alcohol to allow them to be peeled off, or
are clay-based allowing them to dry on the skin and be rinsed
off. Masks can be used for chemical or mechanical exfolia-
tion, or as a vehicle to deliver a therapeutic agent. Most
masks are applied weekly to improve skin hydration, exfoli-
ate, and unclog pores. Physical abrasive agents are also
added to enhance mechanical exfoliation. There is a diversity
of masks on the market. Antiacne masks may include ingre-
dients such as salicylic acid or sulfur, while soothing masks
contain honey or green tea. Other masks are manufactured
with algae, cucumber, essential oils, and soy.
Toners are products used after skin cleansing to clean
soap or cleanser residue and remove remaining sebum and
make-up incompletely removed with cleansers. Inconsistent
nomenclature leads to confusion, as toners are also referred
to as astringents, skin fresheners, toning lotions, clarifying
lotions, or pore lotions. Toners are either alcohol based or
non-alcohol based. Their use in dermatology is predomi-
nantly integrated in antiacne regimens or for antiseptic and
antimicrobial functions. Different formulations developed
for antiacne benefits contain salicylic acid or high tannin
contents. Toners developed for dry skin contain honey, allan-
toin, and aloe vera. Witch hazel, tea tree oil, eucalyptus, and
alpha hydroxy acids are also in many new over-the-counter
astringents and toners. Side effects include contact dermati-
tis and irritation depending on the concentration of alcohol
or solvents that disrupt the epidermal barrier function.
Regardless of nomenclature, these products are widely used
and because of the aesthetically pleasing feeling they give to
the skin, they are generally well accepted by patients.
7 Photoaging
7.1 Key Points
1. Photodamage is the visual and tangible effect of ultravio-
let radiation.
2. Ultraviolet radiation damages collagen, increases elastin
breakdown, and alters extracellular membrane proteins in
the skin.
3. Photodamage also produces free radicals, which break
down cell membranes, proteins, and DNA.
The concept of photodamage encompasses visual and tan-
gible damage to the skin as a result of ultraviolet radiation
[50]. Sun-exposed skin can develop fine rhytids, roughness,
dyschromia, and skin cancer. UV exposure causes epidermal
1187
thickening and disruption of the normal architecture of con-
nective tissue within the dermis. Ultraviolet radiation dam-
ages the cross-linked structure of collagen and elastin fibers,
and decreases the amount of glycosaminoglycans (GAG),
particularly hyaluronic acid, within the dermis [51]. Chronic
ultraviolet damage causes the accumulation of abnormal elas-
tin and fibrillin referred to as solar elastosis. UV radiation
also disrupts the extracellular membrane (ECM) proteins,
namely, the GAG that bind to water and help hydrate and sup-
port the skin. In photodamaged skin, GAG is preferentially
deposited in the elastotic areas rather than in their normal
location between collagen and elastin fibers, thus causing the
characteristic leathery appearance. Photodamage produces
free radicals that break down cell membranes, proteins, and
DNA [52]. Research has shown these changes reflect upregu-
lation of AP1 transcription factor, which activates collagen
breakdown and blocks collagen gene expression, further
impairing collagen synthesis [53]. Free radicals also cause the
upregulation of NF-kappa-B transcription factor, which stim-
ulates the release of pro-inflammatory cytokines such as
TNF-alpha, Il-1, Il-6, and IL-8 [54]. Within the dermis, this
loss of collagen results in the appearance of fine lines, saggy,
thinner skin. The complex changes of aged skin reflect
decreased cell adhesion and differentiation, loss of collagen
and GAG, and increased elastic tissue breakdown [55, 56].
8 Retinoids
8.1 Key Points
1. Retinoids are vitamin A derivatives, which bind to nuclear
retinoic acid receptors and modify gene expression.
2. Retinoid derivatives are found in many prescription and
over-the-counter products.
3. Retinoids have been shown to be effective in the treat-
ment of acne and the improvement of photoaging.
4. Patient education regarding their proper use can enhance
compliance and decrease skin irritation.
Over 20 years of research has confirmed the importance
of retinoids for the integrity of mucosal and epithelial sur-
faces [57, 58]. Retinoids are an example of a group of prod-
ucts that are both a drug and a cosmeceutical. The
delinineation between drug and cosmeceutical depends on
the concentration of the product, the formulation, and the
vehicle in which the retinoid is delivered.
Retinol (vitamin A), its derivatives, and oxidized metabo-
lites, which possess vitamin A activity are formulated as both
naturally occurring and synthetic chemicals in cosmeceuti-
cals. Vitamin A is a naturally occurring derivative of beta-
carotene. However, synthetics are now formulated to mimic
the pharmacologic properties of vitamin A in varying degrees
and lower irritancy profiles [59].
1188
Retinol (Vitamin A)
Retinaldehyde
All-trans retinoic acid
13-cis retinoic acid 9-cis retinoic acid
Fig. 2 Retinol metabolism
Oxidized retinol, or retinoic acid, is the active ingredient
in most cosmeceuticals (all trans, 9-cis, and 13-cis retinoic
acids). Retinol, or its oxidized form, binds three isoforms of
nuclear family receptors known as retinoic acid receptors
(RAR) and retinoid X receptors (RXR) [60]. RARs bind all-
trans retinoic acid, and RXRs bind 9-cis or 13-cis retinoic
acid. Upon binding, a heterodimer is formed, which translo-
cates into the nucleus to bind retinoic acid response elements
on DNA, thereby modifying gene expression.
In the skin, through a series of enzymatic reactions, reti-
nol is metabolized to retinaldehyde, all-trans retinoic acid,
and finally to 9-cis and 13-cis retinoic acids. By products of
this multi-step process produce storage forms known as reti-
nyl esters (retinyl palmitate and retinyl propionate). Both the
metabolites and the storage forms have some biologic activ-
ity, are less irritating, and have been used in cosmeceuticals
for their ability to convert to retinoic acid when applied
exogenously [61] (Fig. 2).
Multiple well controlled trials have demonstrated the ben-
efits of retinoids in reducing fine lines, roughness, and dys-
pigmentation [62–64]. Retinol has been heavily used in
cosmeceuticals for its ease of penetration, ability to convert
to tretinoin, and lower irritancy profile [65]. Studies have
also shown retinol’s efficacy in increasing dermal collagen,
GAG and anchoring fibrils, protecting from oxidative dam-
age, inhibiting lipid peroxidation, increasing keratinocyte
differentiation and cell turnover, and decreasing the number
of sebocytes [66, 67]. However, use of retinol in over-the-
counter preparations has not been shown to be as effective in
antiacne preparations and reducing the signs of photoaging
as prescription tretinoin [58, 68]. Retinaldehyde, which con-
verts to tretinoin, has also been shown to improve signs of
aging [69].
Multiple third-generation retinoids have been developed.
Adapalene and tazarotene are both regulated as drugs, and
have similar action to tretinoin. Adapalene is only approved
for topical acne and has a decreased irritancy profile as com-
pared to tretinoin. However, few studies have shown any
benefit of these agents with regard to efficacy in treating
signs of photoaging [70, 71]. Tazarotene is approved for
plaque-type psoriasis and acne [72]. Although effective in
the treatment of acne, it can be irritating to the skin and has
not been proven effective for photoaging (Table 5).
L. Talakoub et al.
Table 5 Types of retinoids
Naturally occurring Metabolic and synthetic derivatives
Retinol (vitamin A alcohol) Tretinoin (all-trans-retinoic acid)
Retinal (vitamin A aldehyde) Isotretinoin (13-cis-retinoic acid)
Retinoic acid (vitamin A acid) Etretinate
Etretin
Arotinoid
Adapalene
The main side effects of retinoids are their potential for
teratogenicity and their irritancy. This irritation can be mini-
mized by decreasing dosing frequency as well as slow
upward titration of the dosing on initiation of use. A thor-
ough conversation with patients regarding application tech-
niques can enhance patients’ compliance and decrease
frustration. Patients should be carefully educated regarding
optimal application of retinoids, including application of a
small “pea-sized” amount to the entire face at night 20 min
after washing the treatment area. Patients should also be
warned about teratogenicity and photosensitivity reactions
with the use of these medications.
9 Antioxidants
9.1 Key Points
1. Ultraviolet radiation induces the formation of reactive
oxygen species in the skin.
2. Reactive oxygen species are implicated in skin cancer and
cutaneous photoaging .
3. Vitamins, minerals, and natural products with antioxidant
properties have been widely incorporated into skin care
products.
4. Further research is needed to identify the ability of these
agents to scavenge free radicals when applied topically.
The skin is subject to daily exogenous reactive oxygen
species (ROS) such as pollution, UV radiation, and drugs.
Ultraviolet radiation induces the formation of reactive oxy-
gen species in the skin and impairs the skin’s ability to neu-
tralize these ROS [73, 74]. The skin has the ability to cope
with these reactive oxygen species by endogenous mecha-
nisms that scavenge free radicals, bind metal ions, and
remove oxidatively damaged compounds.
Extensive studies have been performed over the last decade
on reactive oxygen species and aging [75, 76]. Reactive oxy-
gen species (ROS) are superoxide anions, peroxide, and sin-
glet oxygen, all of which are generated by exposure of skin to
UV radiation [77]. In vitro studies illustrate that ROS-induced
upregulation of transcription factor AP-1 increases matrix
Antiaging Cosmeceuticals
metalloproteinases (MMP), causing collagen breakdown and
NF-kappaB-induced inflammatory mediators, all of which
contribute to the aging process [78–80].
This section will review the many vitamins, minerals, and
natural products with antioxidant properties. Many of the
mentioned benefits are anecdotal and cannot be quantita-
tively measured when these agents are topically applied.
Well-designed trials are lacking, and correlations to topical
applications are often made from evidence from studies of
these agents following oral administration.
9.2 Vitamin B3: Niacinamide
Vitamin B3, also known as niacinamide, is the precursor to
the ubiquitous molecule nicotinamide adenine dinucleotide
(NAD) and NADP. The reduced forms, NADH and NADPH,
are potent intracellular antioxidants [81]. NAD and NADP
are the primary mediators in cell REDOX reactions as well
as in preventing the protein glycation mechanism that occurs
when sugars cross-link with proteins. Vitamin B3 is among
the water-soluble vitamins that easily penetrate the stratum
corneum when topically applied.
Studies that highlight the numerous roles of niacinamide
on the skin include the prevention of photoimmunosuppres-
sion, photocarcinogenesis, reduction of acne severity, reduc-
tion in TEWL, and decreased appearance of photoaging,
including improved texture and hyperpigmentation [82–84].
Vitamin B3 has been shown to inhibit melanosome transfer
from melanocytes to the keratinocytes [85]. In vitro studies
also elucidate its role in collagen synthesis, synthesis of
ceramides for barrier protection, increasing involucrin, filla-
grin, decreasing sebum production, and preventing TEWL
[36, 86, 87].
9.3 Vitamin B5: Panthenol
Vitamin B5, also known as pantothenic acid, is a component
of the coenzyme A complex, which plays an integral role in
fatty acid synthesis and gluconeogenesis. Vitamin B5 is water-
soluble vitamin easily absorbed topically through the stratum
corneum. It is currently used topically in the treatment of
wounds, bruises, scars, pressure and dermal ulcers, thermal
burns, post-op incisions, and radiation dermatitis [88].
Panthenol, the alcohol of pantothenic acid, is currently
found in many skin care products and cosmetics. Its func-
tions include the promotion of fibroblast proliferation for
wound healing, increased lipid synthesis, and improvement
of signs of photoaging and hyperpigmentation. It is often
used in hair products as it improves elasticity and augments
softening of the hair.
1189
9.4 Vitamin C
Vitamin C is a water-soluble, essential nutrient necessary for
the normal structure and function of the skin. The antioxi-
dant properties of vitamin C are due to its ability to donate
electrons to neutralize free radicals. Vitamin C also helps to
regenerate another antioxidant, vitamin E. Vitamin C is nec-
essary in the hydroxylation of proline and lysine during col-
lagen cross-linking, and the transcriptional regulation of
collagen synthesis. Vitamin C also inhibits the elastin bio-
synthesis seen in aged elastotic skin.
Vitamin C’s role in photoaging is linked to its ability to
stimulate collagen repair as well as its ability to prevent
UVB-induced erythema and sunburn cell formation, both
markers of photodamage [89]. Multiple well-controlled
studies have shown its benefits in decreasing the appearance
of fine lines, biopsy-proven increase in type I collagen
mRNA, increased elastic tissue repair, and clinically
improved skin texture and pigmentation [90, 91]. Studies of
patients who applied 5% L-ascorbic acid to one arm and
vehicle to another arm have biopsy-proven increase in
mRNA levels of collagen I and III and increased matrix
metalloproteinase-1 [92].
There are three forms of vitamin C: L-ascorbic acid (least
stable, oxidized by air), ascorbyl-6-palmitate, and magne-
sium ascorbyl phosphate (most stable). Although oral sup-
plementation is available, little absorbed vitamin C is
delivered effectively to the skin. Topical preparations are
also difficult to formulate as it is oxidized in air and degraded
by light and heat. Topical preparations of L-ascorbic acid or
its ester derivatives are percutaneously absorbed depending
on the concentration of the ascorbic acid and its pH [93]. The
pH of the topical preparation must be <3.5 to allow it to pen-
etrate the thick stratum corneum.
Other vitamin C derivatives have similar properties to
L-ascorbic acid. Magnesium ascorbyl phosphate also func-
tions as an antioxidant, stimulates type-I collagen produc-
tion, and protects against UVB-induced lipid peroxidation.
Ascorbyl-6-palmitate, the fat-soluble analog of L-ascorbic
acid, can penetrate the stratum corneum better than
L-ascorbic acid and has a lower irritancy profile due to its
neutral pH.
9.5 Vitamin E
Vitamin E, also known as alpha-tocopherol, is also an essen-
tial nutrient that cannot be endogenously synthesized.
Vitamin E is normally found in vegetables, vegetable oils,
cereals, and nuts. It is a lipophilic antioxidant, and the most
abundant antioxidant in the skin. Though there are few well-
controlled studies effectively delineating the functions of
1190
vitamin E in normal tissues, some of its purported benefits
include its ability to scavenge lipid peroxyl radicals, thereby
preventing lipid membrane peroxidation [94].
Synergistic functions include the ability of vitamin C to
regenerate vitamin E and enhance the antioxidant capacity of
vitamin E [95]. They work symbiotically to provide photo-
protection against UVR [96]. Small studies have shown
decreased erythema, edema, DNA adduct formation, lipid
peroxidation, and sunburn cell formation when vitamin E is
applied before UVR exposure [97]. Decreased skin rhytido-
sis and skin tumor incidence has also been reported resulting
from topical vitamin E.
Oral vitamin E supplementation can increase the delivery
of vitamin E to the skin via sebaceous gland secretion [98].
However, the vitamin E supplied would only be available to
the upper epidermis at the level of the pilosebaceous units.
Topical preparations range in concentrations from 0.1 to
20%, though there is no dose–response relationship and thus
no proof regarding the amount of vitamin E that is required
to achieve clinical efficacy. Side effects of topical prepara-
tions include irritant allergic contact dermatitis, urticaria,
and erythema multiforme-like eruptions.
9.6 Ubiquinone
Ubiquinone, also known as coenzyme Q, is a ubiquitous lipid-
soluble antioxidant that is present in the mitochondria of all
living cells and utilized in the synthesis of adenosine triphos-
phate (ATP). It has been shown to reduce peroxidation of low-
density lipoproteins, regenerate endogenous vitamin E, and
protect cells against UVR-induced oxidative stress [99, 100].
Topical preparations have illustrated decrease in
UV-induced DNA damage, increase in the levels of GAG,
and protection against UV-induced collagen degradation.
Clinically, ubiquinol cream has been shown to decrease
wrinkle depth as compared to vehicle cream in split-face
trials [101].
9.7 Alpha-Lipoic Acid
Alpha-lipoic acid (ALA) is an endogenous antioxidant that
is a potent free radical scavenger. Similar to ubiquinone, it is
made in the mitochondria of human cells. Little alpha-lipoic
acid is in active circulation as most of the soluble lipoic acid
is bound to lysine. Free ALA is either transported to tissues
or converted to dihydrolipoic acid (DHLA).
Lipoic acid acts as a cofactor in the citric acid cycle and
in nucleic acid and protein synthesis. It is a small mole-
cule, both lipid and water soluble, and thus readily pene-
trates the stratum corneum. Both ALA and DHLA scavenge
ROS and regenerate endogenous antioxidants such as
L. Talakoub et al.
vitamin E, C, glutathione, and ubiquinol, important func-
tions in the protection of UV-induced damage [102]. ALA’s
antioxidant and anti-inflammatory properties are due to the
selective inhibition of NF-kappa-B activation and inhibi-
tion of pro-inflammatory mediators such as TNF-alpha and
interleukins.
There are no well-controlled trials delineating the benefits
of ALA for cutaneous photodamage. Anecdotal evidence
suggests its role in the reduction of fine wrinkles and
improved skin texture [103].
9.8 Dimethylaminoethanol (DMAE)
DMAE is a novel ingredient initially used in the treatment of
hyperkinetic disorders and to improve memory. It is now
being used in cosmeceutical products, gaining popularity
from its activity as a precursor to acetylcholine. Initially uti-
lized as a firming and antiaging product, new functions
including anti-inflammatory and antioxidant activities have
now been elucidated. In vitro, DMAE inhibits IL-2 and IL-6
secretion in addition to its actions as a free radical scavenger.
Although the exact mechanism of action of DMAE is unclear,
its acetylcholine-like functions increase contractility and cell
adhesion in the epidermis and dermis, resulting in the appear-
ance of firmer skin.
Double-blind trials of 3% DMAE facial gel showed
improved facial skin firmness and increased muscle tone as
evidenced by decreased neck sagging [104]. Topical formu-
lations are also now available with little irritancy profile.
Few well-controlled studies exist documenting its long-term
efficacy and toxicity.
9.9 Genistein
Derived from the soybean, this antioxidant when taken orally
has been shown to protect against bladder, breast, colon, liver,
lung, prostate, and skin cancers in animal studies [105]. Topical
genistein scavenges free radicals, protects against lipid peroxi-
dation, and decreases UV-induced erythema and photodamage.
Of particular interest is the ability of genistein to inhibit tyro-
sine protein kinases and UV-induced expression of proto-onco-
genes necessary for tumor growth and progression [106].
9.10 Spin Traps
Spin traps are nitrone derivatives including: DMPO
(5,5-Dimethyl-1-pyrroline-N-oxide), DEPMPO (5-Diethoxy
phosphoryl-5-methyl-1-pyrroline-N-oxide), TEMPONE-H
(1-Hydroxy-2,2,6,6-tetramethyl-4-oxo-piperidine), and
alpha-(4-pyridyl-n-oxide)-N-tert-butyl nitrone (POBN). The
Antiaging Cosmeceuticals
Table 6 Other antioxidants
Other antioxidants
Melatonin: Melatonin is an endogenous hormone
secreted by the pineal gland, with an ability
to scavenge free radicals. Anecdotal studies
have shown an ability of melatonin to
suppress UV-induced erythema [107, 108]a,b.
No well-controlled studies exist as to its
efficacy in cosmeceutical preparations
Catalase: Catalase is an endogenous antioxidant present
in all human cells. Biochemically, its function
resides in its ability to catalyze the
decomposition of hydrogen peroxide to water
and oxygen [109]c
Glutathione: Glutathione is a ubiquitous water-soluble
peptide present in all human cells, made of
glutamic acid, cysteine, and glycine. It also
functions as an antioxidant by scavenging
free radicals induced by UVR
Glucopyranosides: Glucopyranosides are potent antioxidants
also known as resveratrol and polydatins.
They are often found in fruits and vegetables,
with the highest proportion in grape skins.
They function to prevent lipid peroxidation of
cell membranes
Cysteine: Commonly known as N-acetylcysteine
(NAC), a precursor to glutathione, cysteine is
a potent endogenous antioxidant. NAC has
been shown to protect against UV-induced
immunosuppression and can modulate the
expression of oncogenes and tumor
suppressor genes [110]d
Furfuryladenine: Furfuryladenine (Kinerase®) is a growth
factor found in plants that slows the natural
aging process of plants. Cut leaves exposed to
furfuryladenine remain green, while
unexposed leaves turn brown. It is used in
antiaging skin products as in vitro studies
have shown some antiaging benefits [111]e.
Few well-controlled trials have been done as
to its efficacy in vivo
Carnosine: Carnosine (beta-alanyl-l-histidine)
complexes with metal ions. It is believed to
rejuvenate senescent cultures of human
fibroblasts
Uric acid: Uric acid, a product of purine metabolism, is
thought to function by scavenging iron and
copper
a
Bangha et al. [107]
b
Fischer et al. [108]
c
Zaw et al. [109]
d
Kang et al. [110]
e
Rattan [111]
formation of free radicals is secondary to electrons that
spin out of the ground state to a less stable free radical state.
Spin traps are free radical scavengers that trap these spinning
electrons and bring them back to a state of stability. These
agents, when added to creams and sunscreens, scavenge
free radicals and prevent against oxidative damage (Tables 6
and 7).
1191
Table 7 Antioxidants in skin care products
Antioxidants
Vitamin A Allantoin
Vitamin E Furfuryladenine
Vitamin C Niacinamide
Vitamin B DMAE (dimethylaminoethanol)
Panthenol Uric acid
Lipoic acid Carnosine
Co-enzyme Q 10 (ubiquinone) Spin traps
Glucopyranosides Melatonin
Polyphenols Catalase
Cysteine Superoxide dismutase
Glutathione Peroxidase
10 Hydroxyacids
10.1 Key Points
1. Chemo-exfoliation is the mechanism by which natural or
synthetic products are used to slough cohesive corneocytes.
2. Three main chemo-exfoliants used in dermatology
include alpha hydroxy acids, beta hydroxy acids, and
poly hydroxy acids.
3. These agents have been shown to improve skin texture,
skin barrier function, and the appearance of photoaging,
Aging and many skin disorders are due to defects in the stra-
tum corneum’s ability to desquamate. There are thermal,
mechanical, and chemical exfoliating techniques. This section
will focus on chemo-exfoliation, a mechanism by which natural
or synthetic products are used to slough cohesive corneocytes.
These chemicals include AHAs (alpha hydroxy acids), BHAs
(beta hydroxy acids), and PHAs (poly hydroxy acids) [112].
Alpha hydroxy acids (AHAs) are carboxylic acids derived
from plants and synthetically made for use in chemical exfo-
liating products. Many of these naturally occurring acids are
neutralized for over-the- counter use. At low concentrations,
these products reduce corneocyte adhesion, thereby decreas-
ing scale [113]. When applied in higher concentrations and
at low pH values, these same AHAs cause epidermolysis via
cleavage of the desmosomal attachment sites of the basal
layer [114]. This effect can then produce varying degrees of
exfoliation of the skin [115]. The different AHAs include the
following: glycolic acid (derived from sugarcane), lactic acid
(derived from sour milk), citric acid (derived from citrus
fruits), mandelic acid, malic acid, and tartaric acid (derived
from grapes) [116].
AHAs are useful in the management of various cosmetic
and dermatologic conditions including dry skin, seborrheic
dermatitis, callosities, acne scarring, actinic and seborrheic
keratoses, warts, and photodamaged skin [117]. Cosmetic
use of AHA has gained great attention over the last decade as
1192
studies have shown improvement of the skin texture as a
thinner epidermis has better light reflectance qualities [118].
BHAs, the most well known of which is salicylic acid,
also increase epidermal shedding [119]. Other BHAs include
beta-lipohydroxyacid (B-LHA) and tropic acid. The primary
role of these agents is to enhance corneocyte shedding with-
out any significant benefits in the deeper dermis [120].
Salicylic acid is lipophilic and can penetrate the sebum
enriched follicular infundibulum of the pilosebaceous unit. It
is widely used in over-the-counter acne products as it has
been shown in multiple studies to have the ability to dislodge
comedones and prevent the formation of new comedones.
PHAs are a new generation of AHAs developed to provide
similar beneficial effects with less irritancy compared to AHAs
[121]. The polyhydroxy acids include lactobionic acid, galac-
tose, and gluconic acid. In comparison with AHAs, which are
single-strand molecules, polyhydroxy acids are larger, multi-
ple-strand molecules with slower skin penetration, slower
absorption, and reduced irritancy. PHAs can be used on patients
with sensitive skin, including patients with rosacea and atopic
dermatitis [122]. PHAs also have humectant properties and can
enhance stratum corneum barrier function. Similar to AHA,
PHAs possess antioxidant properties and are used to improve
the appearance of photoaged skin [123–125].
10.2 Mechanism of Corneocyte Shedding
The precise mechanism of corneocyte shedding is still under
investigation. Some authors claim that AHA and BHA have
the ability to bind calcium in tissues, resulting in a loss of
calcium at cell-to-cell adhesions resulting in chemical exfo-
liation. Alternative hypotheses for the mechanism of chemi-
cal exfoliation include induction of keratinocyte apoptosis.
10.3 Mechanism of Skin Moisturization
AHA has been shown in small studies to increase the synthe-
sis of dermal GAG, improve the quality of elastic fibers, and
increase the density of collagen. These changes are thought
to be due to an increased collagen mRNA and hyaluronic
acid content of the epidermis and dermis. Studies show GA
(glycolic acid) at 2% concentration demonstrates an increase
in hyaluronic acid content in the epidermis and dermis and
an increase in collagen mRNA gene expression in the AHA-
treated sites compared to vehicle treatment alone [126].
10.4 Mechanism in Barrier Repair
Despite their exfoliative properties, repeated AHA and BHA
use over 4 weeks has been shown to have no effect on
L. Talakoub et al.
TEWL. Studies evaluating mice treated with daily glycolic
or lactic acid demonstrate that the treated mice had a thinner
stratum corneum with no change in TEWL and a paradoxical
increase in lamellar bodies compared to untreated controls
[127]. Thus, despite their ability to induce corneocyte shed-
ding and desquamation, they in fact help to improve the bar-
rier function of the skin.
10.5 Mechanism of Anti-tumorogenesis
Glycolic and tartaric acid have distinct anti-tumorogenic
properties. Glycolic acid has been shown to block UV-induced
apoptosis in mice treated twice daily after UVR. Treated mice
had lower activation of AP-1 and NF-kappa-B, and approxi-
mately a 20% reduction in skin tumor incidence compared to
untreated controls [128]. Similarly, mice irradiated with UVB
and salicylic acid 30% for 18 weeks had a decreased number
of skin tumors compared to untreated mice [129].
10.6 Mechanism of Skin Lightening
Both glycolic and lactic acids can inhibit tyrosinase activity,
thus suppressing melanin formation. Secondary effects are
increased penetration of lightening agents by improving
epidermal turnover and the improvement of the appearance
of hyperpigmentation by increasing keratinocyte shedding
[130]. AHA 10–40% nightly can be compounded with 4%
hydroquinone to treat photoaged skin and dyspigmentation.
10.7 Other Benefits for Photoaged Skin
Glycolic acid improves skin texture, fine wrinkling, and
hyperpigmentation. Well-controlled trials of 8% glycolic and
8% L-lactic acid creams show a decrease in mottled hyper-
pigmentation, roughness, and overall sallowness of photo-
aged skin. AHA at 25% concentration increases dermal acid
mucopolysaccharides, elastic fibers, and collagen density.
These agents further enhance the appearance of acne and
photoaging when used in combination with tretinoin with no
added irritancy than that of tretinoin alone [131].
Although the keratolytic properties of AHA are stronger
than BHA, careful use of both of these harsh chemicals is
warranted as their acidic properties can induce significant
photosensitivity, epidermal damage, and scarring. Although
these agents decrease tumorgenicity induced by UVR, the
high epidermal turnover increases the intensity of the expo-
sure of the epidermis and dermis to UVR. Salicylates that
are percutaneously absorbed also pose the potential risk of
salicylate toxicity if applied over a large body surface area
or to a compromised epidermal barrier. These risks are typ-
Antiaging Cosmeceuticals 1193

Table 8 Types of hydroxy-acids Table 9 Botanical antioxidants

Alpha hydroxy acids Beta hydroxy acids Poly hydroxy acids Botanical antioxidants
Glycolic acid Salicylic acid Gluconic acid Flavones Rutin (apples, blueberries)
Lactic acid Beta-lipohydroxyacid Lactobionic acid Quercetin (apples, blueberries)
(B-LHA) Hesperidin (lemons, oranges)
Tartaric acid Tropic acid Galactose Diosmin (lemons, oranges)
Citric acid Soy
Silymarin (milk thistle)
Xanthones Mangiferin (mango plant)
ically evident with uses of high concentrations of salicylic Mangostin (bilberry plant)
Carotenoids Astaxanthin (tomatoes)
acid ointment or salicylic acid, not at the concentrations or
Lutein (tomatoes)
body surface areas used in over-the-counter acne treat-
Lycopene (tomatoes)
ments. These products are category B (lactic and glycolic
Polyphenols Rosmarinic acid (rosemary)
acid) and C (salicylic acid) and thus should be used with
Hypericin (St. John’s wort)
great caution in pregnancy, lactation, and in young Ellagic acid (pomegranate fruit)
children. Chlorogenic acid (blueberry leaf)
The multifaceted effects of hydroxyacids all contribute to Oleuropein (olive leaf)
the ability of these agents to improve signs of aging, includ- Curcumin (tumeric root)
ing the appearance of fine lines, hyperpigmentation, and skin Pycnogenol (marine pine bark)
texture (Table 8). Terpenoids (ginko biloba)
Procyandin (grape seed )
Epigallocatechin (Green Tea)
11 Botanicals

11.1 Key Points
1. There has been increasing demand for botanical agents in
skin care products.
2. Botanicals are chemicals extracted from the leaves, barks,
roots, and flowers of plants.
3. There are thousands of botanical agents with purported
therapeutic benefits; however, their use in skin care prod-
ucts varies considerably based on harvest and extraction
techniques.
4. Further research is needed to define the optimal concen-
tration, beneficial properties, and side effects when botan-
icals are used in topical preparations.
Over the last 5 years, there has been an increasing demand
for botanical products and their development. Consumers are
more aware of ingredients in the products they use and natu-
ral ingredients are now a part of most skin care products in
the US market [132]. Some botanicals have proven physio-
logic benefits, whereas many others are synthetic variants of
plant extracts that may or may not have the same benefits of
naturally occurring ingredients.
Botanicals are extracted from the leaves, barks, roots,
and flowers of plants. They undergo grinding, distilling,
pressing and drying to make a liquid, powder paste, syrup,
or crystal and are then further processed chemically, often
heated to derive the essential oils incorporated into products
[133]. Through the aforementioned vigorous processing and
heating, many natural extracts lose their beneficial
properties. Additionally, the amount extracted from each
plant may not be in sufficient quantities to deliver the pur-
ported benefits.
There are thousands of naturally occurring extracts of
plants with physiologic benefits, with each natural extract
containing a large number of active components [134]. Many
of the extracts work synergistically to provide a therapeutic
benefit. As opposed to synthetic products that are made
under standardized conditions, botanicals differ in efficacy
and toxicity depending on time of harvest, weather, prepara-
tion of the herb, and final extraction [135]. The efficacy of
botanical products is primarily based on anecdotal evidence,
rather than scientific investigation and they are considered
dietary supplements or food additives, excluding them from
FDA regulations. This chapter will focus on the most widely
used botanicals in skin care products.
Most botanicals may be classified into categories compris-
ing their suggested benefit. The botanical antioxidants are
further subclassified into flavonoids, carotenoids, and poly-
phenols. Antioxidant botanicals quench singlet oxygen and
reactive oxygen species, such as superoxide anions, hydroxyl
radicals, fatty peroxy radicals, and hydroperoxides (Table 9).
11.2 Soy
Soy is a naturally occurring isoflavone comprised of genis-
tein and daidzein. Soy is also classified as phytoestrogen,
due to its structural similarity to estrogen, and has received
1194
significant attention due to studies suggesting preventative
benefits in cardiovascular disease and breast cancer in the
Asian population [136]. Like estrogen, soy also has the abil-
ity to increase skin thickness and promote collagen gene
expression. The genistein component of soy products pro-
vides the antioxidant effects by acting as a scavenger of free
radicals and an inhibitor of lipid peroxidation [137].
11.3 Curcumin
Curcumin is derived from tumeric root and has been used for
years as a food additive and spice. Curcumin is a polyphenol
antioxidant with many other anti-inflammatory functions
[138]. Multiple human studies have shown curcumin’s anti-
inflammatory activity as an inhibitor of leukotriene, lipooxy-
genase, and cyclooxygenase, as well as an inhibitor of
platelet aggregation, and stabilizer of neutrophilic lysosomal
membranes [139]. It has also been shown to inhibit collage-
nase, elastase, and hyaluronidase [140]. The hydrogenated
form, tetrahydrocurcumin, is also a potent antioxidant and
the form most often added to products.
11.4 Silymarin
Silymarin is extracted from the fruit, seeds, and leaves of the
milk thistle plant, Silybum marianum. It is a mixture of three
types of flavonoids: silibinin, silydianin, and silychristin. All
function as potent antioxidants by scavenging free radicals,
preventing lipid peroxidation, and decreasing the production
of pyrimidine dimers. Hairless mice treated with silymarin
prior to UVB exposure have a significant decrease in number
of skin carcinomas [141]. This effect is thought to be due to
the ability of silymarin to prevent the formation of pyrimi-
dine dimers and to prevent angiogenesis [142].
11.5 Pycnogenol
Derived from the French marine pine bark, Pinus pinaster,
pycnogenol is a water-soluble polyphenol, which functions
as a free radical scavenger and antioxidant [143]. Pycnogenol
also augments the antioxidant effects of both vitamins C and
E. It is used orally for the prevention of cardiovascular dis-
ease and is also used topically for the prevention of cutane-
ous oxidative damage. There have been no reported adverse
side effects from topical or oral use of pycnogenol.
11.6 Kinetin
Kinetin is a cytokinin, or adenine derivative, found in various
plants and human cells. This product, referred to in skin care
L. Talakoub et al.
products as N6-furfuryladenine, has been shown to improve
the appearance of photoaging by decreasing fine wrinkles,
improving pigmentation, and increasing skin smoothness. It
is a strong antioxidant used to slow the yellowing of leaves
and the over-ripening of fruits. Although the exact mecha-
nism of action is unknown, kinetin provides benefits in DNA
repair, prevents oxidative protein damage, and decreases
TEWL when applied topically [144].
11.7 Ginkgo Biloba
Ginkgo biloba is an extract of the plant group known as ter-
penoids. It is a polyphenol antioxidant known to increase
superoxide dismutase in the epidermis after topical applica-
tion. Studies in fibroblast models suggest its role as a free
radical scavenger and its ability to prevent lipid peroxidation
[145]. Ginkgo biloba has also been shown in vitro to stimu-
late human fibroblast proliferation and increase collagen and
fibronectin formation. There have been no large in vivo stud-
ies evaluating its antiaging effects [94].
11.8 Teas
Tea leaves are a rich source of polyphenols. They are strong
natural antioxidants able to scavenge singlet oxygen, super-
oxide radicals, hydroxyl radicals, and hydrogen peroxide.
Teas have been shown in numerous in vitro studies to inhibit
UV-induced skin cancer formation [147]. They have the abil-
ity to regenerate vitamin E, reduce UV-induced pyrimidine
dimers, inhibit angiogenesis factors such as VEGF, and pre-
vent against UV-induced erythema and sunburn cell forma-
tion [147, 148].
11.9 Tea Tree Oil
Tea tree oil is an essential oil consisting of terpene. It has
antimicrobial properties for gram-positive and gram-negative
infections, herpes simplex virus, candida and Trichophyton
[149]. Topical applications of tea tree oil are used for the
treatment of acne and onychomycosis. Tea tree oil has the
ability to reduce histamine-induced type I hypersensitivity
reactions. Since it is a sun sensitizer and can be cytotoxic to
epidermal cells exposed to UVR, it should not be used for
burns or on sunburned skin. Tea tree oil is also a significant
cause of allergic contact dermatitis [150].
11.10 Grape Seed
Grape seed oil is derived from the seeds of various varieties
of Vitis vinifera grapes. Grape seed extract is a polyphenol
Antiaging Cosmeceuticals
composed of procyanidins (aka proanthocyanidin, leukocy-
anidin, and tannins). Procyanidins have potent antioxidant,
anti-inflammatory, and anti-carcinogenic properties.
Although no clinical trials have been performed, anecdotal
reports suggest beneficial effects of grape seed for hair
growth, wound healing, UV protection, and the stabilization
of elastin and collagen by inhibition of matrix metallopro-
teinases. Topical formulations of grape seed extract have
been used for years for its ability to inhibit histamine synthe-
sis, promote wound healing, improve photoaging, reduce
post-op edema, reduce venous insufficiency, and reduce UV
radiation-induced sunburn cell formation and immunosup-
pression [151].
11.11 Soothing Agents
Soothing agents include prickly pear, aloe vera, allantoin,
witch hazel, and papaya. These agents contain 80% water,
10% sucrose, tartaric acid, citric acid, and other mucopolysac-
charides. The evaporation of water from topical application of
these agents causes cooling of the skin and the mucopolysac-
charides provide a protective coating over wounded skin.
11.12 Aloe Vera
Aloe vera is one of the most widely used botanical agents. It
is made from a colorless gel extracted from the aloe vera
plant. It is composed of 99.5% water and a complex mix of
mucopolysaccharides, amino acids, hydroxyquinone glyco-
sides, and minerals. It has been shown to accelerate wound
healing and to protect and soothe the skin. It is antibacterial
to Staphyloccocus species, H. pylori, dermatophyte fungus,
and also has viricidal properties against herpes and varicella.
Aloe vera increases blood flow, reduces inflammation, and
enhances wound healing [152]. In topical preparations, it has
been shown to increase collagen synthesis in wounds. Aloe
vera is found in a wide range of over-the-counter products
including soaps, shampoos, and moisturizers. Side effects
include allergic contact dermatitis and potential carcinogenic
properties, which makes it contraindicated in pregnancy and
lactation.
11.13 Allantoin
Allantoin is extracted from the comfrey root and is often syn-
thetically derived. It is added to many products to treat burns,
dermatitis, wounds, acne, and impetigo. It is also added to
sensitive skin moisturizers, hand sanitizers, and in topical
formulations for the treatment of scars and keloids [153]. It
is carcinogenic and thus contraindicated in pregnancy and
lactation and can be fatal when orally consumed.
1195
12 Other Botanicals
12.1 Witch Hazel
Derived from the leaves of the witch hazel plant, the witch
hazel extract contains a high proportion of tannins that func-
tion as topical vasoconstrictors. Witch hazel is used as an
astringent for oily skin and is useful for the treatment of
venous varicosities and spider veins.
12.2 Glycyrrhizin
Glycyrrhizin is found in licorice root and inhibits the pro-
inflammatory activities of prostaglandins and leukotrienes
[154].
12.3 Ginseng
Ginseng is one of the steroidal saponins known as ginsengo-
sides. Ginseng enhances immunity, increases protein synthe-
sis, and has antioxidant, antiviral and antitumor properties.
12.4 Capsaicin
Extracted from cayenne peppers, capsaicin inhibits sub-
stance P. It is often used for the treatment of pruritis and pain.
12.5 Podophyllotoxin
Podophyllotoxin is extracted from the mayapple. It has viri-
cidal properties and thus used for the treatment of condy-
loma and verruca vulgaris.
12.6 Echinacea
Echinacea extract is derived from the echinacea plant and
has been anecdotally shown to stimulate immunity, protect
collagen, and has antioxidant and antimicrobial properties.
Its widespread uses include the treatment of stomatitis,
wounds, burns, prevention of infection, and the treatment of
ulcers and photoaging.
12.7 Garlic
Garlic is an alliin and allicin polysaccharide. It contains
saponins, vitamin A, B2, and C. Garlic has antimicrobial and
antioxidant properties, as well as anti-yeast and anti-
dermatophyte activity.
1196
12.8 Saw Palmetto
Saw palmetto is also a member of the flavonoid antioxidants.
It has anti-androgenic, anti-estrogenic, and anti-inflammatory
activities.
12.9 St. John’s Wort
St. John’s wort is a wound healing agent with anti-
staphylococcus and anti-inflammatory activity.
12.10 Pomegranate
Pomegranate consists of 25% tannin polyphenols such as
ellagic acid, in addition to ascorbic acid, niacin, and piperi-
dine alkaloids. It inhibits gram-negative bacteria, fungus,
parasites, viruses, and has photoprotective properties [155].
12.11 Chamomile
Chamomile, a member of the composite family, is an anti-
inflammatory, anti-allergic, antimicrobial, and antioxidant anal-
gesic botanical. It inhibits the release of histamine, lipooxygenase,
and cyclooxygenase. Its ability to stimulate granulation tissue
formation has stimulated its use in wound healing [156].
12.12 Lavender
Lavender is also a plant extract that has anti-inflammatory,
antimicrobial, and antiallergic properties. Lavender has been
shown to inhibit mast cells. Its wide range of uses includes
topical preparations therapeutic for bites, burns, wounds,
acne, psoriasis, HSV, and fungal infections [157].
The growing consumer demand for all-natural ingredients
in foods and over-the-counter products has increased interest
in botanicals for skin care. Little evidence in human trials
support their efficacy and the rigorous processing prior to
their use in cosmeceuticals often depletes the beneficial
properties of the extract. Despite this, the use of botanicals is
widespread and will continue to expand as the demand for
natural products increases.
13 Skin Lightening
13.1 Key Points
1. Skin lightening agents include phenolic and non-phenolic
compounds.
2. The mechanism of skin lightening by topical agents
includes decreased tyrosinase synthesis, increased
L. Talakoub et al.
tyrosinase degradation, melanocyte toxicity, increased
keratinocyte desquamation, or decreased melanosome
transfer to keratinocytes.
3. There are no reliable, safe, and universally effective skin
depigmenting agents.
4. Increased debate over the safety of hydroquinone has
stimulated research into alternative, safer agents for skin
lightening.
Hyperpigmentation results from an increased number of
melanocytes or an increased production of melanin. Despite
the many acquired or hereditary disorders of pigmentation,
few products have been developed to effectively and evenly
depigment the skin. In particular, pigmentation from UVR,
drugs, melasma, post-inflammatory pigmentation, acne scar-
ring, poikiloderma of Civatte, ephelides, and solar lentigos
still remain some of the most prevalent patient concerns with
little treatment options that provide proven benefits.
Management focuses on photoprotection and topical depig-
menting agents available in skin care products [158, 159].
14 Phenolic Agents
14.1 Hydroquinone
Hydroquinone is a skin lightening agent available as either a
pharmaceutical or a cosmeceutical. Its mechanism of action
depends on its ability to inhibit tyrosinase synthesis, thereby
inhibiting the production of melanin. Other functions of
hydroquinone include its ability to inhibit DNA and RNA
synthesis and degrade melanosomes [160]. Products sold at
2% concentration are available in more than 100 over-the-
counter products, while those with 3–10% concentration are
prescription products and regulated as drugs. New products
on the market today use hydroquinone in combination with
topical retinoids and topical steroids for treatment of
melasma and photopigmentation [161].
Hydroquinone has received scrutiny recently due to its
risk of ochronosis, a severe but rare side effect. Endogenous
ochronosis is a manifestation of a rare metabolic disorder
known as alkaptonuria, resulting from a deficiency of homo-
gentisic acid oxidase; exogenous ochronosis is a rare cutane-
ous side effect of long-term use of topical depigmenting
agents such as hydroquinone. Ochronosis is characterized by
an asymptomatic blue-black pigmentation of skin and carti-
lage. Although the exact cause of ochronosis from topical
hydroquinone is not known, studies suggest that hydroqui-
none may inhibit homogentisic acid oxidase in the dermis,
with the accumulation of homogentisic acid in the dermis
causing ochronotic pigment deposition. Other agents
reported in the literature causing exogenous ochronosis are
antimalarials, resorcinol, phenol, mercury, or picric acid.
A recent literature review reveals only 22 reported cases
of ochronosis with hydroquinone use in over 10,000 patient
Antiaging Cosmeceuticals
exposures over 50 years. This is an extremely low risk and
hydroquinone can be safely used in patients. Most cases of
ochronosis reported were with the long-term use of hydro-
quinone in doses greater than those in topical over-the-
counter preparations. Although cases of ochronosis with the
use of 2% hydroquinone has been reported, dermal absorp-
tion of hydroquinone up to 4% has been shown to be equiva-
lent to that absorbed from ingestion of common foods
containing hydroquinone. The risk of ochronosis is report-
edly greater in African American women, when the product
is used on large surface areas, at concentrations greater than
4%, for extended periods of time [162].
Hydroquinone at 2% concentration is widely used in topi-
cal cosmeceutical preparations. The current recommenda-
tions for its use are on hyperpigmented lesions for
approximately 4–6 weeks. The benefits of hydroquinone are
reportedly evident in the first 4–6 weeks of use and plateau at
4 months. Use beyond 4 months is generally not
recommended.
Combination products containing hydroquinone include
the Kligman formula, which contains 5% hydroquinone with
0.1% retinoic acid and 0.1% dexamethasone in a hydrophilic
ointment base [163]. Newer products such as Tri-Luma
cream contain 0.01% fluocinolone, 4% hydroquinone, and
0.05% tretinoin [164].
The FDA has proposed warnings as to the carcinogenic
potential of hydroquinone. Hydroquinone, a metabolite of
benzene, is an inhibitor of DNA and RNA synthesis. High
doses of hydroquinone used for extended periods of time
have been shown in lab animals to cause hepatic adenomas,
renal adenomas, and leukemia. Allegations of hepatic and
renal adenomas stem from murine studies and have not been
reported in humans with oral or topical hydroquinone.
Additionally, hydroquinone has been implicated in animal
studies to cause mononuclear cell leukemia. The leukemo-
genic potential is only in the presence of phenol, and has
only been described in murine studies after high dose oral
intake for over 2 years. No mononuclear cell leukemia has
been reported with topical use of hydroquinone [165].
In conclusion, the FDA’s proposed ban on the use of
hydroquinone in over-the-counter preparations is based on
carcinogen studies not validated in human trials. Ochronosis
is however a documented side effect of hydroquinone use
and all patients should be advised against long-term use of
hydroquinone-containing products.
14.2 Arbutin
Arbutin, hydroquinone-beta-D-glucopyranoside, is a crystal-
lized extract of the bearberry plant. Its mechanism, similar to
hydroquinone, involves the inhibition of tyrosinase activity.
However, unlike hydroquinone, it does not inhibit the syn-
thesis of tyrosinase, rather it inhibits tyrosinase activity by
acting as a molecular mimic to the amino acid tyrosine [163].
1197
14.3 N-Acetyl-4-S-Cysteaminylphenol
N-acetyl-4-S-cysteaminylphenol is a phenolic thioether
depigmenting agent used in the treatment of solar lentigos. It
is cytotoxic to melanocytes that are actively producing
eumelanin. Few studies also suggest an antitumor effect
against the proliferation of melanoma cells in vitro [166].
N-acetyl-4-S-cysteaminylphenol is more stable and less irri-
tating compared with hydroquinone. Combination products
containing N-acetyl-4-S-cysteaminylphenol and tretinoin are
also available.
15 Non-phenolic Agents
15.1 Kojic Acid
Kojic acid is derived from aspergillus and penicillium fungi.
It also functions as a tyrosinase inhibitor by chelating copper
ions needed for tyrosinase function [167]. This agent has
been used in the food industry to prevent browning of foods
and to redden unripe tomatoes. It is available in concentra-
tions of 1–4%. Unlike hydroquinone, it has a high incidence
of irritant contact dermatitis and is often used in combination
products with corticosteroids to reduce its irritant profile.
Kojic acid is also reportedly a potent scavenger of reactive
oxygen species and is consumed orally for its proposed anti-
aging and anticancer benefits.
15.2 Licorice Extract
Licorice extract is also known as Glabridin. The licorice root
is a tyrosinase inhibitor derived from the root of Glycyrrhiza
glabra linneva tree [168]. A combination product containing
0.4% glabridin, 0.05% betamethasone, and 0.05% retinoic
acid has been shown to be effective in the treatment of
melasma; however, it is not available in the United States. No
specific adverse effects have been reported.
15.3 Paper Mulberry
Paper mulberry is also a tyrosinase inhibitor extracted from
the Broussonetia papyrifera root bark [169]. No long-term
studies provide any data on its efficacy. No significant
adverse side effects have been reported.
15.4 Soy
As previously mentioned, soybeans have many clinically
significant properties. Its depigmenting function is due to the
inhibition of the phagocytosis of melanosomes by keratino-
cytes [170].
1198
15.5 Vitamin C
Vitamin interferes with pigment production at various stages
of the melanin synthesis pathway. Vitamin C interacts with
copper ions at the tyrosinase active site blocking the forma-
tion of melanin.
15.6 Melatonin
Melatonin is an endogenously produced hormone synthe-
sized by the pineal gland in response to sunlight and diurnal
rhythms. Its depigmenting functions are secondary to the
inhibition of tyrosinase in melanocytes.
15.7 Glycolic Acid
Glycolic acid is derived from sugar cane and is most com-
monly used as an exfoliating agent. Glycolic acid in high
concentrations can function to lighten skin by stimulating
corneocyte desquamation. By stimulating the shedding of
the top layers of the skin, it also enhances the penetration of
other topical skin lighteners.
15.8 Aloe
Aloe vera is a noncompetitive inhibitor of tyrosinase and a
competitive inhibitor of DOPA (dihydroxyphenylalanine)
oxidation. Aloe vera has been shown to inhibit UV-induced
melanogenesis.
15.9 Niacinamide
Niacinamide, vitamin B3, inhibits the transfer of melano-
somes to keratinocytes.
15.10 Azaleic Acid
Azaleic acid is a naturally occurring dicarboxylic acid iso-
lated from Pityrosporum ovale. Azaleic acid is a weak com-
petitive inhibitor of tyrosinase activity. Azaleic acid also
inhibits thioredoxin reductase, an enzyme needed for DNA
synthesis and thus has additional anti-proliferative and cyto-
toxic effects on melanocytes. Azaleic acid topically used in a
20% cream has a variety of therapeutic uses including
treatment for acne, rosacea, lentigines, and hyperpigmenta-
tion [171].
L. Talakoub et al.
15.11 Retinoids
Retinoids have also been shown to decrease the pigmentation
of melasma and post-inflammatory pigmentary alteration
[172]. Studies have shown that retinoids disperse the mela-
nin pigment in keratinocytes with a loss of supranuclear caps
in the basal layer. Retinoids also function to impede melano-
some transfer to keratinocytes and increase epidermal turn-
over (Fig. 3, Tables 10 and 11).
Despite many years of research and significant scientific
interest in skin lightening agents, there are no reliable, safe,
and universally effective skin depigmenting agents. Synthetic
products and botanical agents show some promise; however,
studies evaluating their safety and efficacy are lacking. The
debate over the safety of hydroquinone will continue to stim-
ulate researchers and industry to find a safer alternative in
years to come.
16 Metals
16.1 Key Points
1. Metals play a critical role in the integrity of skin, hair, and
nails.
2. Their use in sunscreens and antimicrobial agents has
been well elucidated; however, further research is
needed to define their benefits in topical antiaging
preparations.
There are many skin disorders due to deficiencies of met-
als. These include zinc deficiency – acrodermatitis entero-
pathica and copper deficiency – Menkes disease. These
deficiency dermatitides illustrate the integral role of metals
in maintaining the integrity of skin, hair, and nails.
16.2 Zinc
Zinc is a ubiquitous metal critical to the stability and activity
of enzymes required for DNA replication, gene transcription,
and protein synthesis. It is essential for proper wound heal-
ing, signaling, and structure of the ECM. Zinc is used in topi-
cal preparations for barrier protection, wound healing, and
treatment of inflammatory disorders [173]. Its use as a broad-
spectrum sunscreen has been documented in studies that
illustrate decreased oxidative stress on UV radiated skin
fibroblasts treated with topical zinc preparations.
Antifungicidal properties of zinc pyrithione have also stimu-
lated it use in antidandruff shampoos [174].
Antiaging Cosmeceuticals 1199

The Melanin Chemical Pathway

TYROSINASE

HO O

HO COOH HO N COOH O N COOH

N
H2 H2 H2

Tyrosine Dopa Dopaquinone

HO
+ Cysteine
HO N COOH
H
Leucodopechrome

O
+
HO N COO–
H
NH2
DOPACHROME Dopachrome
HO
HC COOH
TAUTOMERASE CO2
CH2
HO N COOH
H2 S
S HO HO
HO
CH2
HC COOH HO N COOH HO N
HO N COOH H
H2 H
NH2 5,6-Dihydroxyindole 5,6-Dihydroxyindole
5-8-Cysteinyldopa 2-8-cysteinyldopa 2-carboxylic acid

TYROSINASE
Benzothiazine Intermediates RELATED PROTEIN-1 Quinones

Pheomelanins Eumelanins

Fig. 3 Chart of tyrosinase pathway

Table 10 Mechanism of action of depigmenting agents

Mechanism of action of depigmenting agents
Inhibition of tyrosinase synthesis Retinol, kojic acid, hydroquinone, arbutin, glabridin, ellagic acid, paper
mulberry, azaleic acid, monobenzyl ether of hydroquinone
Decreased tyrosinase synthesis Ascorbic acid, aloesin
Decreased tyrosinase transfer Glucosamine, tunicamycin
Tyrosinase degradation Linoleic acid
Toxicity to melanocytes Hydroquinone, monobenzyl ether of hydroquinone
Increased desquamation of keratinocytes Retinoids, alpha and beta hydroxy acids, linoleic acid
Decreased melanosome transfer to keratinocytes Nicinamide, retinol, soy

16.3 Copper
An essential cofactor for the proper functioning of many
enzymes. Copper plays an instrumental role in the function
of tyrosinase necessary for melanin synthesis and the func-
tion of lysyl oxidase required for collagen synthesis.
Additionally, copper is a cofactor for superoxide dismutase,
which scavenges free radicals that cause oxidative damage to
the skin. Topically applied copper has been shown in small
studies to improve skin roughness, increase collagen
synthesis, and improve the appearance of fine lines and pho-
todamage [175].
16.4 Selenium
Selenium is an essential element in plants. It is required for
the function of glutathione peroxidase and thioredoxin
reductase, both of which protect cells against oxidative dam-
age. Selenium has strong antioxidant abilities, protecting
1200 L. Talakoub et al.

Table 11 Depigmenting agents Table 12 Anti-cellulite cosmeceuticals

Depigmenting agents Anti-cellulite
Phenolic Hydroquinone Isopropylarterenol hydrochloride Aminophylline
Monobenzylether of hydroquinone Epinephrine Caffeine
4-Methoxyphenol 9OHIMBINE Phentolamine
4-Isopropylcatechol Piperoxan Dihydroergotamine
4-Hydroxyanisol Theophylline Theobromine
N-acetyl-4-S-cysteaminylphenol Barley Gingko
Non-phenolic Corticosteroids Butcher’s broom Green tea
Retinol Centella Ivy
Azelaic acid Witch hazel Thistle
N-acetylcystein (NAC) Algae
l-ascorbyl-2-phosphate
Kojic acid
designed to slow down lipogenesis or increase lipolysis. Fat
Niacinamide
Ascorbic acid
breakdown or lipolysis is inhibited by alpha-2 adrenergic
Arbutin receptors and stimulated by beta-adrenergic receptors [179].
Paper mulberry Agents that stimulate beta-adrenergic receptors thereby
Soy increase fat breakdown. These agents include theobromine,
Combination Kligman’s formula = 5 % hydroquinone, theophylline, aminophylline, caffeine, isopropylarterenol
0.1 % tretinoin, 0.1 % dexamethasone in hydrochloride, and epinephrine. Agents that inhibit alpha-2
hydrophilic ointment adrenergic receptors and thereby prevent the inhibition of
Pathak’s formula = 2 % hydroquinone and lipolysis include yohimbine, piperoxan, phentolamine, and
0.05–0.1 % tretinoin
dihydroergotamine [180] (Table 12).
Westerhof’s
formula = 4.7 % N-acetylcysteine (NAC), Although many of these agents have been developed for
2 % hydroquinone, and 0.1 % triamcinolone topical use, none have been proven in well-controlled studies
acetonide to provide reproducible benefit. Further research is needed to
delineate the etiology of cellulite and its treatment.

cells against DNA oxidation, lipid peroxidation, and

UV-induced DNA damage [176]. Selenium’s antimicrobial 18 Enzymes
properties are beneficial in antidandruff treatments.
18.1 Key Points

17 Anticellulites 1. Topically applied enzymes are now being developed with

17.1 Key Points
1. There is no clear consensus as to the etiology of
cellulite.
2. Topical preparations have been designed to alter fat break-
down mechanisms; however, none have been proven in
well-controlled studies to provide reproducible benefit.
Over the last decade, many new cosmeceuticals have been
developed for over-the-counter products claiming to improve
the appearance of cellulite. Few such products are studied in
well-controlled trials.
There is no consensus as to the etiology of cellulite or its
female predilection, and no criteria that can effectively mea-
sure its improvement.
Topical treatments are designed to change the metabolism
of adipocytes [177, 178]. These topical preparations are
anecdotal benefits for photodamaged skin.
2. Further research is needed to evaluate the absorption of
these large molecules when used in topical preparations.
Topical lotions with DNA repair enzymes applied to UV
exposed skin have been shown to decrease the development
of actinic keratoses and basal cell carcinomas. Additionally,
topical application of photolyase-containing liposomes
decreases UV-induced cyclobutane dimer formation and
UV-induced immunosuppression, erythema, and sunburn-
cell formation. The most common topically applied enzymes
include papain and DNA repair enzymes.
18.2 Papain
Papain, derived from the papaya fruit, is an enzyme that
digests intracellular protein bonds. Papain when used
Antiaging Cosmeceuticals
topically can improve epidermal exfoliation and can be used
in the treatment of hypertrophic scars [181].
18.3 Deoxyribonucleic Acid (DNA) Repair
Enzymes
Bacteria-derived DNA repair enzymes have been reported to
decrease skin cancer by inhibiting the formation of UVR-
induced cyclobutane pyrimidine dimers. The clinical appli-
cations of DNA repair enzymes are still limited, as many
cannot be topically absorbed.
19 Growth Factors
19.1 Key Points
1. Growth factors are cytokines and proteins that regulate
intercellular signaling, cell growth, cell development, and
tissue repair.
2. Growth factors developed for skin care products include
epidermal growth factor, transforming growth factor, and
platelet-derived growth factor.
3. The ability of these large proteins to penetrate the stratum
corneum is limited, and thus further research is needed to
define their role in topical skin care preparations.
Growth factors (GFs) are naturally occurring cytokines
and proteins that regulate intercellular signaling, cell growth,
cell development, and tissue repair. GFs are derived from
epidermal cells, culture fibroblasts, placental cells, and
plants. Their interactions stimulate tissue repair and immune
response, and increase the synthesis of collagen, elastin,
and GAG.
Growth factors included in skin care products include epi-
dermal growth factor (EGF), transforming growth factor
(TGF), and platelet-derived growth factor (PDGF). EGF,
found in plasma, sweat, urine, saliva, and semen, stimulates
epidermal re-epithelialization and differentiation and has
been used for the treatment of burns and surgical wounds.
TGF augments the production of extracellular matrix pro-
teins for epithelial repair, promotes angiogenesis, and accel-
erates wound healing.
Studies evaluating topical GF mixtures applied to photo-
damaged skin have shown improvement in new collagen for-
mation, epidermal thickening, skin hydration, roughness,
dyspigmentation, blotchiness, and wrinkles [182]. The
wound healing benefits of growth factors have also been
evaluated with use after ablative and non-ablative laser resur-
facing with treated skin exhibiting less erythema and
improved wound healing.
1201
Controversial debate however has arisen in the litera-
ture with respect to the ability of topically applied growth
factors such as VEGF to increase the growth of melanoma
cells in vitro [183]. This concern stems from studies
showing growth progression of in vitro melanomas cells
with the addition of VEGF. Alternatively, studies have
shown in vitro growth inhibition of squamous cell carci-
noma with the addition of VEGF and TGF-beta. Other
potentially detrimental effects of growth factors include
the ability of TGF-beta to induce scar formation by acti-
vating fibroblasts and thus promoting the formation of
keloidal scarring [184].
Debate has also arisen as to whether or not large proteins
such as growth factors can penetrate the stratum corneum.
Studies are now under way evaluating novel delivery sys-
tems that disrupt the stratum corneum, therefore allowing
high-molecular-weight molecules such as growth factors to
penetrate into the dermis [185, 186]. These investigated tech-
niques include liposomal transdermal delivery, micropora-
tion, phonophoresis, and iontophoresis.
20 Hormones
20.1 Key Points
1. Endogenous hormones play a key role in the integrity of
human skin, hair, and nails.
2. The exogenous application of estrogen and testosterone is
under investigation; however, their use in topical prepara-
tions are currently limited.
The cutaneous manifestations of endocrinopathies such
as skin changes seen in menopause, hypothyroidism, hyper-
insulinemia, and Addison’s disease have been well defined in
the dermatology and endocrinology literature.
Many studies have shown the benefits of topical estrogen
preparations including improving skin texture, wrinkling,
elasticity, and neo-vascularization [187–189]. Small studies
have also shown biopsy-proven increase in type III collagen
in estrogen-treated skin. However, long-term studies on their
efficacy and toxicity are lacking. Topical estrogen and estro-
gen–progesterone preparations are also currently used in
Europe and are effective for the management of hormonal
acne.
Testosterone creams have also gained increased accep-
tance as recent studies postulate oral supplementation
improves memory and sexual function; limited studies how-
ever have been done on the effects of topically applied tes-
tosterone. Side effects of topically applied androgenic
steroids, including acne and hirsutism, have limited their use
in over-the-counter cosmeceuticals.
1202
21 Peptides
21.1 Key Points
1. Peptides are sequences of amino acids that mimic the
amino acids in collagen and elastin.
2. Three classes of peptides used in topical antiaging regi-
mens include signal peptides, carrier peptides, and
neurotransmitter-inhibiting peptides.
3. The ability of these large-molecular-weight compounds
to penetrate the stratum corneum is limited and thus few
studies have shown any sustainable benefit.
Photoaged skin exhibits decreased synthesis of procolla-
gen I mRNA in fibroblasts, thicker elastotic fibers, and
increased matrix metalloproteinases. Peptides are sequences
of amino acids that mimic the amino acids in collagen and
elastin and are believed to increase collagen and elastin syn-
thesis. One caveat of peptide use in skin products is the
inability of these large- molecular-weight compounds to
penetrate the stratum corneum.
There are three types of peptides used in cosmeceuticals:
signal peptides, carrier peptides, and neurotransmitter-
inhibiting peptides.
Signal peptides are short-chain amino acids that augment
communication between cells. One example of a signal pep-
tide in cosmeceutical products is valine-glycine-valine-
alanine-proline-glycine (VGVAPG). This amino acid
sequence has been shown to stimulate human skin fibroblast
production, downregulate elastin expression, and promote the
chemotaxis of fibroblasts [190]. An alternative peptide, tyro-
sine-tyrosine-arginine-alanine-aspartic-alanine, inhibits pro-
collagen C-proteinase, an enzyme that cleaves C-propeptide
from procollagen-I and thereby decreases collagen break-
down. Alternatively, lysine-threonine-threonine-lysine-serine
(Pal-KTTKS – Strivectin® and Regenerist®) is also a signal
peptide found in type I procollagen. This pentapeptide has
been shown to stimulate in vitro synthesis of collagen type I,
IV, and fibronectin [191].
Carrier peptides are peptides with an ability to deliver met-
als to the skin. The tripeptide glycyl-L-histidyl-L-lysine facili-
tates copper uptake by the cell. Copper is a cofactor for lysyl
oxidase, the enzyme needed for collagen synthesis. This tri-
peptide also increases levels of MMP-2 and increases the level
of inhibitors of metalloproteinases TIMP-1 and TIMP-2.
Neurotransmitter-inhibiting peptides such as the hexa-
peptide known as Argireline® (acetyl-glutamyl-glutamyl-
methoxyl-glutaminyl-arginyl-arginylamide) function similar
to botulism toxin. Argireline mimics the N-terminal domain
of SNAP-2,5 blocking the formation of the SNARE complex
needed for docking vesicles for acetylcholine release [192].
This synthetically derived peptide is marketed to provide the
same muscle relaxing and wrinkle-reducing effects as
L. Talakoub et al.
BOTOX®. However, when topically applied, these agents do
not effectively penetrate the skin to reach the deeper muscles
in concentrations needed to provide benefits similar to
BOTOX injections. Limited safety and efficacy studies have
been performed to prove any sustainable benefits.
The use of peptides in cosmeceuticals is still a novel con-
cept with limited studies. The large size of these molecules
limits is penetration through the stratum corneum. Although
safety and efficacy data are lacking, many of these products
are popularly used in over-the-counter antiaging regimens.
22 Proteins
22.1 Key Points
1. Proteins are agents developed to improve skin and hair
hydration
Protein when applied topically has the unique ability to
bind and hold water in the skin. Similar to a humectant, the
ability to hold water improves the appearance of aged skin
by providing hydration and assisting in barrier repair.
Proteins have also been added to many hair conditioners to
restore hair shaft fractures induced by aging and repeated
trauma [193]. Proteins are also manufactured in hair-styling
products as they neutralize the charge from static electricity
often present on the hair shaft.
23 Antiacne Agents
Many of the products previously mentioned in this chapter
including retinoids, salicylic acid, and azelaic acid are useful
in the management of acne [194]. As previously alluded to,
salicylic acid is comedolytic, anti-inflammatory, and pro-
motes epidermal desquamation and turnover. Retinol-based
products eliminate microcomedones, enhance epithelial
turnover, and decrease sebum production. Azelaic acid is a
naturally occurring botanical with mild antimicrobial and
mild keratolytic activity. Other naturally occurring cosme-
ceuticals include niacinamide, which increases desquama-
tion and decreases sebum production.
Over-the-counter benzoyl peroxide preparations are com-
monly used for their antimicrobial and anti-inflammatory ben-
efits. Topical preparations containing 1–10% sulfur are mild
keratolytics and bacteriostatic agents against P. acnes. Sodium
sulfacetamide is also a bacteriostatic agent with activity
against both gram-positive and gram-negative bacteria.
Although many of these products have relatively mild side
effects including irritation and dryness, sulfur-based products
have been shown to induce life-threatening hypersensitivity
reactions and should be avoided in patients with a sulfa allergy.
Antiaging Cosmeceuticals 1203

Table 13 Skin care regimen by skin type

Skin care regimens Cleanser Moisturizer Toner Other agents Avoid
Oily skin Syndet with Lotion – oil free On oily areas only Niacinamide Mineral oil
oil-soluble to remove excess Salicylic acid
detergent sebum or soap Glycolic acid
residue
Soap Lactobionic acid
Salicylic acid Witch hazel
Papaya
Soy
Retinol
Zinc
Talc
Oil absorbing powder
Dry skin Syndet Cream None Glycerin Soaps
Mild cleanser Should be oil-based with Panthenol Strong cleansers
mineral oil, petrolatum, Sodium PCA Gels, aerosolized sprays,
lanolin, dimethicone, or Ceramides water based lotions
cyclomethicone Urea Abrasive scrubs
Cholesterol Toners
Lactic acid Astringents
Acetone
Propylene glycol
Glycolic acid
Salicylic acid
Fragrances
Dyes
Sensitive skin Syndet Cream None Prickly pear Soaps
Mild cleanser Should be oil based with Green tea Strong cleansers
mineral oil, petrolatum, or Saw palmetto Gels, aerosolized sprays,
dimethicone St. Johns wort water based lotions
Ginkgo biloba Abrasive scrubs
Evening Primrose oil Toners
Tea tree oil Astringents
Allantoin Acetone
Aloe vera Propylene glycol
Panthenol Glycerin
Bisabolol Glycolic acid
Salicylic acid
Lactic acid
Fragrances
Dyes

24 Anti-redness Agents 25 Irritancy

Facial redness is multifactorial. Genetics, superficial telangiecta- 25.1 Key Points

sias, and cutaneous disorders including seborrhea and rosacea all
contribute to the appearance of flushed, red skin. Surface vasodi-
lation and inflammation can be reduced by skin care products
containing vasoconstricting and anti-inflammatory agents.
Product ingredients used for erythema include soothing agents
such as prickly pear and aloe vera, humectants such as panthenol,
and anti-inflammatory agents such as green tea [195]. Moisturizers
and cosmetics have also been developed with green tinted color-
ings to help camouflage erythema. Patients with facial redness
should avoid products containing harsh acids such as salicylic
acid. Products with fragrance enhance irritancy and can poten-
tially worsen facial erythema. Furthermore, sunscreens should be
applied daily to prevent UV-induced erythema (Table 13).
1. Irritant and allergic dermatitis is common with over-the-
counter skin care products.
2. Fragrances, preservatives, and vehicles are common cul-
prits of irritancy or hypersensitivity.
3. Patient education regarding product ingredients and their
proper use can enhance compliance and decrease skin
irritation.
Contact dermatitis, either irritant or allergic, is seen com-
monly with cosmeceuticals [196]. The lack of reports of proven
contact sensitivity is due to the lack of standardization of these
products, and thus a lack of allergens available for testing.
1204
Although many natural or synthetic products are potent skin
sensitizers or irritants, the vehicles in which these products are
made also contain preservatives, fragrances, and colorings that
can cause irritant or allergic contact dermatitis [197].
To improve consumer satisfaction, many skin care prod-
ucts contain added fragrance. However, most product labels
do not delineate these additives on their packaging.
Additionally, chemicals such as benzyl alcohol and benzyl
aldehyde, often used as a fragrance, can be added to products
for their functions separate from their fragrance. These prod-
ucts are routinely used in “fragrance free” cosmetics.
Similarly, botanicals containing a natural fragrance are not
labeled as containing a fragrance on product labels. Similarly,
products labeled as “unscented” do not imply that no fra-
grance is used; this implies that no odor can be smelled.
Often, unscented products contain masking fragrances
designed to disguise the chemical odor of the agent [198].
Preservatives are also widely used to prevent bacterial
growth and oxidation of cosmeceutical products. These
agents including formaldehyde, formaldehyde releasers,
parabens, kathon CG, Euxyl K 100 are also culprits of
allergic contact dermatitis. Vehicles containing these preser-
vatives are so widespread that it is often challenging for the
patient who has developed an irritant or allergic reaction to
these agents to effectively depict the culprit ingredient.
Patch testing is recommended for any patient with contact
dermatitis. Furthermore, educating consumers and patients
about product ingredients is imperative, particularly when an
unknown or treatment recalcitrant contact hypersensitivity
develops.
L. Talakoub et al.
developed to quantify skin firmness, blood flow, and skin
hydration. These instruments are now in widespread use to
quantify and measure objective parameters, and will be use-
ful in our quest to provide evidence-based recommendations
to our patients.
Conclusion
In 2006, the cosmeceutical market rose to nearly eight bil-
lion dollars in profits in the United States alone. The
development, use, and marketing of these products will
continue to rise as the aging population strives to find
noninvasive alternatives to antiaging regimens. Well-
designed, randomized placebo-controlled trials and basic
science research is lacking. Industry is leading the
research behind many of the science we now know to
influence the development of cosmeceuticals. As the mar-
ket grows, so should our understanding of the products, as
it is our patients who use these products. As leaders of the
field of dermatology, we need to understand the science of
cosmeceuticals to provide our patients with the optimal
education and skin care guidance [4, 25, 200–217].
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 Part X
The Future
 Preventive Medicine and Healthy
Longevity: Basis for Sustainable
Anti-Aging Strategies
Giovanni Scapagnini, Calogero Caruso,
and Giovanni Spera
1 Introduction
In the last century, both human life expectancy and maxi-
mum life span potential increased [1]. The analysis of North
European mortality curves suggests that a relevant role for
this phenomenon was played by the reduction of lifetime
pathogen burden [2]. Whatever was the real cause, at the end
of 1900, the improved hygienic conditions, the proper diet,
the better health condition, and the decreased infant mortal-
ity elevated life expectation up to 80 years, with a conse-
quent raise in elderly population of industrialized countries.
In the society, the public perception of advanced aging
involves the inability to survive alone due to chronic diseases
and the combined loss of mobility, sensory functions, and
cognition [3]. Age-related diseases, such as cardiovascular
diseases, osteoporosis, cancer and neurodegenerative disor-
ders, represent the major cause of morbidity and mortality in
Western countries, with an exponential growth of health
costs linked to increased size of elderly. For example,
Alzheimer’s disease (AD) is the fifth leading cause of death
in Americans aged 65 and older and deaths attributable to
AD have been rising dramatically in the last decade (47 %
increase between 2000 and 2006) [4]. With the increasingly
aging population of the United States, the number of AD
patients is predicted to reach 14 million in 2050, with an
expected incidence of AD nearly to a million people per year
and similar considerations apply worldwide [5]. Similar
G. Scapagnini, MD (*)
Dipartimento Di Scienze Della Salute, Università del Molise,
Campobasso, Italy
e-mail: g.scapagnini@gmail.com
C. Caruso, MD
Unità di Immunosenescenza, Dipartimento di Patobiologia e
Metodologie Biomediche, Università di Palermo, Palermo, Italy
G. Spera, MD
Dipartimento di Fisiopatologia Medica, Università di Roma
“Sapienza”, Rome, Italy
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_82
trends follow main age-related chronic diseases. This will
pose an immense economic and personal burden on the
actual and future generations, creating a critical emergency
for effective therapeutic and preventive interventions.
However, there is a judge difference among people that ages:
There are people at the age of 60 years old that have exten-
sive cognitive difficulties and chronic diseases and other that
at 90 years old are still in good mental and physical condi-
tion. Avoiding age-related disease until late in life is key to
“successful” aging. It is possible to transform in reality the
constant dream of humankind: to stop, postpone, and/or
reverse the aging process? During the last years, an increas-
ing number of scientific meetings, articles, and books have
been devoted to antiaging strategies and therapies. This topic
is very popular among the general public, whose imagery has
been fascinated by all possible tools and tricks to retard
aging, thus approaching immortality, but it is also full of mis-
leading, simplistic, or wrong ideas. In almost all instances,
claims of drugs, health supplements, and other types of inter-
vention are not based on any evidence supported by sound
scientific knowledge. Of course, other approaches, including
intervention in telomere shortening, cell cycle control, inter-
fering with the oncogene/anti-oncogene homeostatic bal-
ance, etc. are being studied as possible “antiaging”
manipulations. Although solid data suggesting increased
survival time in vitro or life span expansion in experimental
animals in vivo has been reported in some of these instances,
these interventions are still far from being applicable in the
complex human situation, and must therefore await further
scrutiny, particularly with regard to still unknown side effects
[6]. Thus, in the present chapter, antiaging strategies aimed
not to rejuvenate, but to slow aging and to delay or avoid the
onset of age-related diseases are discussed, allowing to sub-
stantially slow down the aging process, extending people’s
productive, youthful lives. In particular, it will briefly focus
on the most promising approaches proposed to obtain a
healthy longevity: nutritional strategies, physical activity,
and hormone therapy. Furthermore in this context, some
1213
1214
specific skin antiaging aspects will be also discussed. Skin
aging, in fact, is particularly important because of its social
impact, but also represents an ideal model organ for investi-
gating the aging process.
Overall, understanding what aging is means being able to
quantify physical inability, mental functional capacity,
organs and apparatus deregulation.
2 Biology of Aging
Although in the recent years dozens of theories have been
proposed to explain aging, to date biological mechanisms
underlying aging and longevity are only partially under-
stood. Aging is considered as a multifactorial process not
recognizing a single responsible cause, but the result of sev-
eral mechanisms simultaneously interacting at different lev-
els. It is a relentless event that affects all cells, tissues, organs,
and organisms, diminishing homeostasis and increasing
organism vulnerability. Aging results from a breakdown of
self-organizing system and reduced ability to adapt to envi-
ronment and it may be defined as a systemic loss of molecu-
lar fidelity that, after reproduction, reaches levels that exceed
repair, turnover, or maintenance capacity. Current biological
thinking emphasizes that organisms are encoded for early
survival and reproduction to prevent the species from extinc-
tion. These considerations suggest that the biological deter-
minants of human aging lie in the fact that human cell
maintenance and repair systems evolved when human life
expectancy was only half what it is today. The host response
mechanisms are limited because they occur at cost of invest-
ments in early survival and reproduction. The aging pheno-
type is a complex interaction of stochastic, genetic and
epigenetic variables whereas genetic variables do not create
the aging phenotype but generate the lost of molecular fidel-
ity and, therefore, as the random accumulation of damage in
the human cells, tissues, or whole organism during life
changes the performances of most physiological systems and
increases susceptibility to diseases and death. Lipsitz and
Goldberger have suggested that normal human aging is asso-
ciated with a loss of complexity in a variety of fractal-like
anatomic structures and physiological processes; further-
more, using a variety of measures that employ fractal analy-
sis, aging has been shown to be associated with a loss of
complexity in blood pressure, respiratory cycle, stride inter-
val, and postural sway dynamics [7].
3 Cellular Senescence
Cellular senescence, which can be induced by several stimuli,
consists of a state of permanent cell cycle arrest associated
with characteristic changes in cell morphology. Cellular
G. Scapagnini et al.
senescence was first described by Leonard Hayflick in 1961
who observed that cultures of normal human fibroblasts had a
limited replicative potential and eventually became irrevers-
ibly arrested [8]. He proposed that the cell culture phenome-
non could be used as a model to study human aging at a
molecular and cellular level. The majority of senescent cells
assume a characteristic flattened and enlarged morphology,
and over the years a large number of molecular phenotypes
have been described, such as changes in gene expression, pro-
tein processing, and chromatin organization [9]. The growth
arrest occurs mostly in G1 phase [10]. Although individual
cells arrest rapidly, probably within the duration of a single
cell cycle, cultures are typically quite asynchronous with
increasing proportions of cells withdrawing into senescence
over a period of several weeks [11]. Cellular senescence can
be activated by various types of stressful stimuli, including
telomere shortening, oncogenic or tumor suppressor signals,
and DNA damage. The crucial role of telomeres, and the
related enzyme telomerase, in cell turnover and aging has
been then highlighted by several studies. Progressive telo-
mere shortening in successive cell divisions induces senes-
cence due to the loss of terminal sequences during DNA
replication. Maintenance of the telomere sequences at human
chromosome ends is essential for immortalized cells to escape
from the normal limitations of the proliferation capacity [12].
Conceptually, there are two broad categories of replicative
cellular senescence. The first is initiated by dysfunctional
telomeres or other forms of genotoxic stress eliciting a DNA
damage response mediated primarily by the p53 tumor sup-
pressor pathway [13]. The second, much less understood
response does not involve telomeres or DNA damage, and is
characterized by the upregulation of the cyclin-dependent
kinase inhibitor p16INK4a gene. These basic distinctions are,
however, complicated by the fact that p16 can be upregulated
by a wide variety of stresses, including some forms of geno-
toxic damage. However, at the level of tissues or of the entire
organism, what is the impact of telomere shortening? Does
aging cause telomere shortening or does telomere shortening
cause aging? An association between telomere length and
mortality in 143 normal unrelated individuals over the age of
60 years. Those with shorter telomeres in blood DNA had
poorer survival, attributable in part to a higher mortality rate
from heart disease and a mortality rate from infectious dis-
ease. Telomere shortening of blood cells, likely due to
increased rounds of replication depending on lifelong
immune-inflammatory stimuli, contributes to mortality in
many age-related diseases. Hence, these results suggest their
possible role as biomarkers. However, unfortunately they
have not been yet extensively confirmed [14]. Although
numerous data support the idea that the loss of telomere
repeats in stem cells and lymphocytes contributes primarily to
human aging, this notion is not widely accepted and by itself
does not explain aging phenotype [15].
Preventive Medicine and Healthy Longevity: Basis for Sustainable Anti-Aging Strategies
Human stem cells have recently attracted so much general
interest in many fields of biology and clinical medicine
including gerontology. In fact, in healthy individuals, skin
integrity is maintained by epidermal stem cells which self-
renew and generate daughter cells that undergo terminal dif-
ferentiation. Despite accumulation of senescence markers in
aged skin, epidermal stem cells are maintained at normal
levels throughout life. Therefore, skin aging is induced by
impaired stem cell mobilization or reduced number of stem
cells able to respond to proliferative signals. In the skin, exis-
tence of several distinct stem cell population has been
reported. The self-renewal and multi-lineage differentiation
of skin stem cells make these cells attractive for aging pro-
cess studies, and also for regenerative medicine, tissue repair,
gene therapy, and cell-based therapy with autologous adult
stem cells not only in dermatology. In addition, they provide
in vitro models to study epidermal lineage selection and its
role in the aging process [16].
4 Oxidative Stress
One of the most studied hypotheses about aging is that it is
caused by oxidative stress [17]. In the mid-1950s, Denham
Harman proposed the idea that oxidative stress might repre-
sent the major cause of the cellular damage that accompanies
aging and age-associated diseases [18]. From that first intu-
ition, the “free radical theory of aging” has mesmerized the
scientific attention as a possible biological explanation of the
entire aging process. In the last years, oxidative stress has
been linked to a variety of medical problems related to aging,
such as cardiovascular pathologies, cancer, diabetes and neu-
rodegenerative disorders. Furthermore, there are abundant
experimental and observational studies supporting the idea
that aging itself might be caused by the deleterious and
cumulative effects of reactive oxygen species (ROS) gener-
ated throughout the life span [19] and that the efficacy of the
response to oxidative stress is key factor in determining lon-
gevity. Reactive oxygen species (ROS) are ubiquitous in liv-
ing aerobic organisms. They result either from the cells’
metabolism (enzymatic, mitochondrial, and redox metal ion-
derived) or from the action of exogenous physical sources
(e.g., ionizing radiation, UVA) and/or chemical compounds.
The electron transport chain (ETC) is thought to be the main
producer of ROS, and it has been demonstrated that ROS,
produced by the mitochondria, are maintained at a relatively
high level inside the mitochondrial matrix. Given the prox-
imity of mitochondrial DNA (mtDNA) and several func-
tional mitochondrial proteins to the primary ROS generator,
it is possible that these molecules are at a greater risk of
incurring oxidative insults, potentially leading to mitochon-
drial dysfunction. Thus, theoretically, age-related oxidative
stress is thought to lead to mitochondrial DNA (mtDNA)
1215
damage, which results in defective ETC proteins, reduced
ETC activity, and enhanced production of ROS. Although
oxidants may certainly function stochastically, accumulating
evidences have also implicated ROS as specific signaling
molecules, and ROS generation, within certain boundaries,
has been demonstrated to be essential to maintain cellular
homeostasis [20]. In complex organisms, oxidative stress has
been reported to increase in elderly subjects, possibly arising
from an uncontrolled production of free radicals by aging
mitochondria and/or decreased antioxidant defenses.
Regardless of how or where they are generated, a rise in
intracellular ROS levels can lead to cell damages via lipid
peroxidation, protein crosslinkage, and DNA breakage.
Oxidative damages are commonly determined by markers
indicating the end products of oxidation [21]. In particular, it
is possible to measure the quantity of nucleic acid that is
damaged, the amount of end products of lipid peroxidation,
or of protein oxidation [22]. Moreover, because a decrease of
major antioxidant defenses with aging has been suggested
[23], the evaluation of antioxidants levels or their efficacy
has been often utilized as a possible indicator for healthy
aging. Nevertheless, the results of studies investigating oxi-
dative stress in human aging are still controversial, and there
are still limited and conflicting results available in the litera-
ture [24]. An interesting model to evaluate the causative role
of oxidative stress in human senescence are genetic diseases,
such as Down and Werner syndromes, characterized by a
tendency to accelerated aging. There is considerable litera-
ture supporting a major role of oxidative stress in their clini-
cal phenotype, with direct evidence of significant increases
in oxidative DNA damage, protein oxidation and lipid per-
oxidation [25]. Numerous studies have demonstrated that
oxidative stress is increased in frail, institutionalized elderly
people, and may lead to an accelerated aging, while in free
living elderly this increase is not always significant. In vivo
results in elderly humans are quite ambiguous. In numerous
studies plasma malondialdehyde, evaluated by means of the
thiobarbituric acid test, was significantly higher in healthy
elderly population, confirming the presence of increased
lipoperoxidation in old age [26]. Nevertheless, other studies
in healthy older subjects, reported a biological antioxidant
status similar to those of younger elderly subjects [27].
Oxygen free radicals can induce a variety of damage to
DNA, including DNA single and double strand breaks, base
modifications and abasic sites [28].
8-hydroxy-2-deoxyguanosine (8-OHdG) is by far the
most studied oxidative DNA lesion and has gained much
attention because of its mutagenic potential [29]. The for-
mation of 8-OHdG in leukocytic DNA and the excretion
of 8-OHdG into urine have been frequently measured by
HPLC or GC-mass spectrometry to assess oxidative stress
in humans [30]. Although some studies have identified
an age-related increase of 8-OHdG in healthy volunteers
1216
[31], prospective study of oxidatively damaged DNA as a
predictor of risk for age-related pathologies is extremely
difficult and few interesting results have been obtained to
date. Besides the accumulation of oxidation products, sev-
eral studies have associated aging with a progressive loss of
antioxidant defenses [32]. ROS production is largely coun-
teracted by an intricate antioxidant defense system that
includes the enzymatic scavengers superoxidodismutase
(SOD), catalase, and glutathione peroxidase (GSH-Px).
SOD speeds the conversion of superoxide to hydrogen per-
oxide, whereas catalase and glutathione peroxidase convert
hydrogen peroxide to water. The most recently discovered
SOD isozyme is the extracellular SOD (EC-SOD) that
plays a primary role as main enzymatic scavenger of super-
oxide in the extracellular space [33]. Numerous researches
evaluated the impact of aging process on EC-SOD activity,
but the results are yet disparate. There are conflicting evi-
dences about the effect of aging on GSH-Px activity. In the
French PAQUID study, there were no changes in GSH-Px
with age [34]. BELFAST study has shown a decline in
GSH-Px in well free-living nonagenarians [27], and other
studies have demonstrated the same in institutionalized old
subjects [35]. In a recent population-based study, cognitive
decline was associated with lower activity of the protec-
tive selenium-dependent GSH-Px and a higher activity of
Cu/Zn-SOD [36]. In addition to these well-characterized
antioxidant enzymes, a variety of other non-enzymatic,
low molecular mass molecules are important in scavenging
ROS. These include ascorbate, pyruvate, flavonoids, carot-
enoids, uric acid and perhaps most importantly, glutathi-
one (GSH), an ubiquitous antioxidant which is present in
millimolar concentrations within cells. GSH depletion can
enhance oxidative stress; GSH level and the ratio between
GSH and oxidized glutathione (GSSG) are decreased
in models of aging and correction of low tissue glutathi-
one increased longevity [37]. Thus it has been speculated
that glutathione status could be an indicator of health and
functional age. In the BELFAST study, GSH plasma lev-
els were increased in nonagenarians compared to septo-/
octogenarians (Rea et al.). It has been recently shown in
204 volunteers with a broad age spectrum that blood GSH
concentration declines with age [38].
Another study, measuring cysteine/cystine and GSH/
GSSG redox in plasma of 122 healthy individuals aged
19–85 years, showed a steady, linear increase in oxidative
events throughout adult life and in particular that the capac-
ity of the GSH antioxidant system is maintained until 45
years in healthy subjects and then declines rapidly [39].
Besides antioxidants, enzymes, and vitamins, in the con-
text of stress response, eukaryotic cells are able to induce
an evolutionarily highly conserved class of proteins known
as HSPs or stress proteins. Stress proteins belong to mul-
tiple gene families grouped on the basis of molecular size
G. Scapagnini et al.
ranging from 10 to 150 kDa and showing different func-
tions and cellular localization. Some HSPs (such as HSP40
and HSP90) are constitutively expressed, whereas others
(such as HSP32 and HSP70) are mainly induced after expo-
sure of cells to environmental and physiological stressors.
A large body of evidence supports a critical role for HSPs
in cellular protection against ROS and a variety of other
insults, including heat, hypoxia, ischemia, excitotoxicity,
glucose deprivation, cancer, and aging. The cellular pro-
tection of HSPs is attributed to their molecular chaperone
function by facilitating nascent protein folding and refold-
ing or degradation of abnormally folded proteins. Among
the HSPs, the stress-inducible HSP70 is essential for pro-
tecting cells from various denaturing stressors, including
oxidative stress, and has been shown to modulate several
signaling processes that are associated with the regulation
of cell death. Various studies have examined the relation-
ship of HSP70 with aging. Rea et al. [40] examined serum
HSP70 in 60 individuals with ages ranging from 20 to 96
years. They demonstrated a progressive decline in serum
HSP70 levels in older age groups. Similarly, Jin et al [41],
in their study of 327 healthy male donors aged between 15
and 50 years, demonstrated a decline in serum HSP70 at
older ages (between 30 and 50) although at younger ages,
they noted a positive correlation with age. Terry et al. [42],
in their cross-sectional study, have assessed serum HSP70
levels from participants enrolled in either the New England
Centenarian Study (93 centenarian offspring plus 43 con-
trols) or the Longevity Genes Project (87 centenarians plus
83 controls) showing that serum HSP70 levels are lower in
those individuals that reach an advanced age. In addition,
they have suggested that low serum HSP70 levels are associ-
ated with longevity independent of other covariates such as
age, gender, race, income, alcohol, cardiovascular disease,
and a variety of other age-related diseases. Cellular ability
to maintain adequate expression levels of protective genes
such as HSP70 and HSP32, better known as heme oxygen-
ase 1 (HO-1), in response to a stressful insult, such as UV
exposure, seems to be essential to preserve cellular homeo-
stasis, and to delay aging also for the skin [43]. Individual
variability in the efficacy to activate these defensive genes is
due to mechanisms not completely understood that include
genetic makeup, responsible also for different phototypes
and age. At the molecular level, post transcriptional regula-
tion might represent a putative mechanism to modulate indi-
vidual efficiency in the activation of cellular stress response.
Post-transcriptional regulation is fundamental to modify the
half-life of some messenger RNAs [44]. Both HSP70 and
HO-1 have been shown to be post-transcriptionally regu-
lated in various cell lines [45], and this process is thought to
be altered during aging. This evidence has been proposed as
a possible cause for the impaired efficacy of defensive genes
such as HSPs [46].
Preventive Medicine and Healthy Longevity: Basis for Sustainable Anti-Aging Strategies
5 Inflammaging
Aging is accompanied by chronic low-grade inflammation
state, shown by a two to fourfold increase in serum levels of
inflammatory mediators that act as predictors of mortality
independent on pre-existing morbidity. This pro-
inflammatory status of the elderly underlies biological mech-
anisms responsible for physical function decline, and
inflammatory age-related diseases are initiated or worsened
by systemic inflammation [47]. In fact, an inflammatory
response appears to be the prevalent triggering mechanism
driving tissue damage associated with different age-related
diseases, and the term “inflamm-Aging” has been coined to
explain the underlining inflammatory changes common to
most age-associated diseases [48, 49]. It is mostly the conse-
quence of the body’s ability to counteract and modulate the
effects of a variety of stressors, which cause the accumula-
tion of molecular and cellular scars. However, a wide range
of different etiological factors contributes to increased low-
grade inflammatory activity in elderly including a decreased
production of sex steroids, smoking, subclinical disorders
such as atherosclerosis, asymptomatic bacteruria, a higher
amount of fat as well as cellular senescence [50]. Although
inflammation is primarily triggered by the engagement of the
immune system, it has been known since 1999 that the estab-
lishment of replicative cellular senescence in human skin
fibroblasts, leads to a strong shared inflammatory response
involving the transcriptional upregulation of cytokines, such
as interleukins (IL-1, IL-15), their receptors (TLR4), and
chemotactic secreted factors (Gro-a and MCP-1 among oth-
ers) [51]. These results were initially interpreted as idiosyn-
cratic of dermal fibroblasts and to recapitulate in vitro the
inflammatory process associated with wound healing, a sus-
picion strengthened by the observation that such a response
was augmented by high concentrations (10 %) of serum. It is
now known that senescence leads to a coordinated secretion
of a large number of soluble factors [52, 53], the so-called
secretory phenotype, and this occurs in different cell types,
following different stresses. Thus, skin aging is accompanied
by a local pro-inflammatory status. However, both intrinsic
and extrinsic mechanisms, in a vicious circle, through ROS
production and telomere shortening, are responsible for a
pro-inflammatory status of skin, hence worsening skin aging.
6 Anti-aging Strategies
Although, in theory, antiaging interventions could modify
the biochemical and molecular events causing aging, correct
physiological changes responsible for symptoms and signs
of aging, or decrease the susceptibility to disease associated
with aging, to date no single agent has been shown to truly
reverse aging or increase longevity in humans. Nevertheless,
1217
several lifestyle choices, such as performing physical activ-
ity (especially if begun in mid-life), quitting cigarette smok-
ing, maintaining normal blood pressure, and avoiding over
weight, are independently associated with reduced mortality
and improved health span. More importantly, correct nutri-
tional habits can strongly affect health status and aging, food
being the most relevant epigenetic environmental variable.
Furthermore, some light therapeutic intervention might be
beneficial for a healthier aging. As previously stated, aging is
accompanied by a low-grade inflammation held responsible
for many age-related diseases, so a decrease in the rate of
inflammation should prevent the activation of the immune
system. The age-associated increase in pro-inflammatory
cytokines in the elderly raises the possibility that some pro-
inflammatory cytokine-blocking antibodies or soluble recep-
tors could also be beneficial for the elderly. Moreover, there
are other less potent, well-known inflammation-modulating
drugs such as statins and non-steroidal anti-inflammatory
drugs that have few side effects and can be used with safety
even in very old subjects. On the basis of this, it is reasonable
to assume that anti-inflammatory treatments could be useful
to counteract and reduce the age-dependent inflammatory
status [54]. Finally, because several hormones decline over
time during human aging, hormonal substitutive therapy has
been proposed as an effective antiaging strategy.
7 Nutrition
It is well accepted that nutrition can influence or even play a
leading role in the development of various diseases such as
infections, cancer, and CVD. Approximately, 40 micronu-
trients (vitamins, essential minerals, and other compounds
required in small amount for normal metabolism) have been
reported as essential components in the diet [55]. To the
extent that after conscious control of one’s own behavior,
environment, life style, and diet, a degree of control of both
the aging and diseases of aging are potentially possible.
Macronutrients such as antioxidant, dietary fiber, omega-3
as well as micronutrients such as vitamins, zinc, iron, and
copper, and selenium or plant-derived small molecules
such as polyphenols are of particular interest. Thus, nutri-
tional interventions could be beneficial for the prevention,
retardation, or even reversal of established immunosenes-
cence and aging. In a survey recently published, it has been
found that higher adherence to a Mediterranean diet was
associated with a statistically significant reduction in total
mortality. The dominant components of the Mediterranean
diet score as a predictor of lower mortality are moderate
consumption of ethanol, low consumption of meat and
meat products, and high consumption of vegetables, fruits
and nuts, olive oil, and legumes. Minimal contributions
were found for cereals and dairy products, possibly because
1218
they are heterogeneous categories of foods with differential
health effects, and for fish and seafood, the intake of which
is low in this population [56].
8 Caloric Restriction
Caloric restriction (CR), defined as a reduction in organism
energy intake, has been shown to enhance longevity from
yeast to mammals. In particular, CR reduces metabolic rate
and oxidative damage, improves markers of diabetes such as
insulin sensitivity, showing a decreased incidence of cardio-
vascular disease and effects on neuroendocrine and sympa-
thetic nervous system in laboratory animals and some of
these are replicating now in ongoing human studies. In mam-
mals, caloric restriction induces a complex pattern of physi-
ological and behavioral changes, such as reduction in blood
glucose, triglycerides, and growth factors [58].
It has been widely demonstrated that CR effects are medi-
ated by a family of enzymes called Sirtuins that consist of
NAD+-dependent histone/protein deacetylases. In particular,
the Sir2 (silencing information regulator 2) has been demon-
strated affect life span in several species from yeast to rodents
during caloric restriction [59]. In particular, increased Sir2
activity leads to replicative life span extension, but it is still
unclear the molecular link between Sir2 and CR. Deletion of
Sir2 in yeast abolishes the increase in life span induced by
caloric restriction or sublethal levels of stress, indicating that
Sir2 is a mediator of signals that promote longevity [60].
Moreover, an increased dosage of Sir2 proteins extends life
span, while deletion or mutation of Sir2 reaches the opposite
result in several different species [61, 62]. In mammals,
seven homologues of Sir2 gene have been identified to date.
Although all the seven sirtuins are probably equally impor-
tant, most of the studies about mechanisms of action and bio-
logical relevance of these pleiotropic proteins have involved
only SIRT1. Whereas it is not yet known whether the mam-
malian Sir2 ortholog, SIRT1, similarly regulates aging and
longevity in mammals, it has been shown to regulate meta-
bolic responses to changes in nutrient availability in several
tissues, increasing in muscle, brain, liver, and fat in response
to fasting and CR in rodents [63]. Upregulation of SIRT1 in
adipocytes in response to fasting promotes lipolysis and free
fatty acid mobilization through repression of PPAR©, a
nuclear hormone receptor that promotes adipogenesis [64].
SIRT1 also promotes gluconeogenesis and represses glycol-
ysis in hepatocytes in response to nutrient deprivation by
interacting with and deacetylating PGC-1α, a key transcrip-
tional regulator of glucose production in the liver [65]. In
skeletal muscle, SIRT1-mediated PGC-1α deacetylation is
required to induce mitochondrial fatty acid oxidation genes
in states of nutrient deprivation [66]. Finally, Ramsey and
others demonstrated that SIRT1 promotes insulin secretion
G. Scapagnini et al.
in pancreatic cells in response to glucose [67]. Brunet et al
showed that in mammalian cells SIRT1 appears to control
the cellular response to stress by regulating the family of
Forkhead transcriptional factors (FOXOs), a family of pro-
teins that function as sensors of the insulin signaling path-
way and as regulators of organismal longevity [68]. SIRT1
and the transcriptional factor FOXO3 form a complex in
cells in response to oxidative stress, and SIRT1 deacetylates
FOXO3 in vitro and within cells. SIRT1 has a dual effect on
FOXO3 function, increasing FOXO3’s ability to induce cell
cycle arrest and resistance to oxidative stress but inhibiting
its capacity to induce cell death. Thus, one way in which
members of the Sir2 family of proteins may increase organ-
ismal longevity is by tipping FOXO-dependent responses
away from apoptosis and toward stress resistance, by inhibi-
tion of apoptosis and promotion of DNA repair. SIRT1 also
inhibits Bax-induced apoptosis by deacetylating Ku70 [69].
In addition, a recent study demonstrated that SIRT1 can
modulate the cellular stress response directly deacetylating
the heat shock factor (HFS1) and thus regulating heat shock
proteins expression. Inhibiting SIRT1 expression via small
interfering RNA prevents HSF1 from binding to the hsp70
promoter and suppresses transcription of the gene when cells
are exposed to heat shock. Conversely, Westerheide et al.
observed that SIRT1 activation by resveratrol or SIRT1 over-
expression in cells decreases HSF1 acetylation, prolongs
HSF1 binding to target promoters, and enhances the heat
shock response [70]. Moreover, SIRT1 deacetylates the p53
tumor suppressor protein [71], which downregulates p53 via
effects on stability and activity. As increased stress resis-
tance is a frequent correlate of longevity in model organisms,
the ability of SIRT1 to modulate stress resistance in mam-
malian cells suggests a potential link with mammalian aging.
9 Antioxidants
Nutritional supplementation, especially with antioxi-
dants, has been frequently indicated as a potential means
to improve health status and increase longevity. However,
only limited evidence about the protective effects of spe-
cific micronutrients is available. Moreover, it is still unclear
whether the health benefits from diets at high consumption
of fruit and vegetables [72] can be replicated by antioxidant
supplementations. An important part of the evidence sup-
porting the beneficial effects of antioxidant supplementation
is based on animal data. Vitamin C is the major water-sol-
uble antioxidant and acts as first defense against free radi-
cals in whole blood and plasma. It is a powerful inhibitor
of lipid peroxidation and regenerates vitamin E in lipopro-
teins and membranes and a strong inverse association has
been shown between plasma ascorbic acid and isoprostanes
[73]. Vitamin E is thought to have a role in the prevention
Preventive Medicine and Healthy Longevity: Basis for Sustainable Anti-Aging Strategies
of atherosclerosis through inhibition of oxidative modifica-
tions of LDLs. Inhibition of isoprostanes formation by vita-
min E supplementation has been shown in humans [74, 75]
as well as in animal models, and formation of isoprostanes
increases significantly in animals deficient in vitamin E [76].
Recently total plasma carotenoid levels have been suggested
as a possible health indicator in elderly populations. The
“Epidemiology of Vascular Ageing” (EVA) study (n 1389;
59–71 years) has determined the association between base-
line total plasma carotenoids and mortality. Low total plasma
carotenoid level was significantly associated with all-cause
mortality in men but not in women [77]. Even if some epide-
miological studies have shown that antioxidant supplementa-
tion may decrease the risk of several clinical conditions, such
observations are usually not universal. Even the only capa-
bility of reducing oxidative damage through antioxidant sup-
plementation is limited [78]. In conclusion, current evidence
does not allow to recommend antioxidant supplementation
as a useful means to prevent age-related pathophysiologi-
cal modifications and clinical conditions. Several concerns
are present not only about their efficacy, but also on their
safety. According to large prospective studies, antioxidants
have little effect on cerebrovascular and cardiovascular dis-
eases and in fact may even increase overall mortality. On the
other side their role seems to be extremely effective for skin
aging. UV-induced skin damage by ROS is a rapid process,
and antioxidants can prevent the damage when applied at
the beginning or during the development of oxidative stress.
Antioxidant supplementation is an integral part of a multi-
faceted approach in photoprotection. Topical application of
vitamin E has shown to induce smoothening of fine lines and
wrinkles whereas when given as a diet supplement, a lim-
ited cutaneous bioavailability was indicated which is insuf-
ficient to scavenge ROS generated in photoaged human skin.
Topical delivery of these agents is an attractive alternative,
so that they can be used as cosmetic ingredients against skin
aging, especially as curative/therapeutic in addition to their
prophylactic action [79].
10 Polyphenols
In recent years, there has been a growing interest, supported
by a large number of experimental and epidemiological stud-
ies, about the beneficial effects of some commonly used
plant-derived products, often used in traditional or folk med-
icine, in preventing various age-related pathologic condi-
tions. Spices and herbs often contain active substances, such
as polyphenols or alkaloids, endowed with potent antioxida-
tive and chemopreventive properties. Polyphenols are pro-
duced by all higher plants in order to protect them against
biotic and abiotic stress such as UV radiation, temperature
changes, infections, wounding, and herbivores. These
1219
xenobiotics are endowed with potent anti-inflammatory,
antioxidant, photoprotective, and anticarcinogenic proper-
ties, and they appear to have a number of different molecular
targets, impinging on several signaling pathways, such as the
NF-kB pathway and the transcription factor nuclear factor
E2-related factor 2 (Nrf2) pathway, showing pleiotropic
activity on cells and tissues. A possible general mechanism
of polyphenols healing activity relate to their ability to over-
express highly protective inducible genes involved in the cel-
lular stress response. Some of these compounds are among
the most promising agents for a variety of skin disorders, in
particular skin cancer. Thus, botanically derived products
come back popular as topical or oral products in the antiag-
ing dermatological armamentarium.
Green tea, one of the most widely consumed beverages,
has recently attracted scientific attention as a potential nutri-
tional strategy to prevent a broad range of age-related chronic
disorders. Moreover, a number of epidemiological studies
have suggested that consuming green tea on a daily basis, as
part of a lifestyle, might reduce the onset of all cause mortal-
ity and improve longevity [81]. The health-promoting effects
of green tea consumption are mainly attributed to its poly-
phenol content, which represent 35% of the dry weight [81].
Compared to black tea, green tea is particularly rich in cate-
chins, that include (−)- epigallocatechin-3-gallate (EGCG),
(−)-epicatechin-3-gallate, (−)-epigallo-catechin, and epicat-
echin. EGCG is the most active and abundant compound in
green tea, representing approximately 43 % of the total phe-
nols. EGCG possesses antioxidant and anti-inflammatory
properties which include the capacity to inhibit overexpres-
sion of cyclooxygenase-2 and nitric oxide synthase [82] and
has been shown to have photoprotective and anticarcinogenic
activities [83]. It induces apoptosis in several types of cancer
cells by inactivating some transcription factors, such as
NF-kB, AP-1, and STAT-1 [84]. EGCG prevents cancer cell
invasion, angiogenesis, and metastasis by downregulating
the expression of matrix metalloproteinases and by inhibit-
ing the cell adhesion function [85]. Several reports have also
shown the ability of EGCG to induce a general xenobiotic
response in the target cells, activating multiple defense genes
[86]. Epidemiological evidences indicate that populations
with high intake of green tea catechins benefit in terms of
body weight and body fat, glucose homeostasis, and cardio-
vascular health. A large epidemiological study conducted in
Japan showed that subjects with an average habitual con-
sumption of >6 cups of green tea per day had a decreased
risk for diabetes [87]. Overall, the harmonizing effects of
green tea catechins on disorders of glucose metabolism
implicated in type-2 diabetes seem to be mediated by various
mechanisms, including decreased carbohydrate absorption,
decreased hepatic glucose production, increased insulin
secretion and insulin sensitivity, as well as increased uptake
of glucose into skeletal muscle [88]. The role of EGCG in
1220
decreasing UVB-DNA damages, sunburn and erythema has
also well been established while its action in increasing epi-
dermal thickness by inducing keratinocytes’ proliferation
still need to be confirmed.
Red wine represents a source of polyphenols which
exhibit a number of biological effects on various systems; in
this respect, there is evidence that red wine polyphenols con-
stitute one of the ingredients of the Mediterranean diet which
is associated with reduced all cause and cause-specific mor-
tality as CHD. Recently a series of papers focused on some
aspects of the effects of wine polyphenols [89]. The authors
have investigated the ability of red wine polyphenols to pro-
mote the in vitro release of both pro-inflammatory and anti-
inflammatory cytokines from human healthy peripheral
blood mononuclear cells (PBMC) as well as of immunoglob-
ulins from B cells. Following red wine cell pretreatment,
results show a production of regulatory interleukin (IL-12),
proinflammatory (IL-1beta and IL-6), and anti-inflammatory
(IL-10), cytokines, as well as of IgA and IgG. They discussed
the fine balance between inflammation and anti-inflammation,
as well as the role of humoral immune response either sys-
temic or mucosal as a consequence of red wine intake.
Turning on the molecular mechanisms elicited by polyphe-
nols from red wine on PBMC, they investigated their involve-
ment in the activation of p38 and ERK1/2 molecules
belonging to the MAPK kinase family involved in release of
interferongamma, and therefore, in nitric oxide (NO) pro-
duction. Results demonstrated that in cells both expression
of p38 and ERK1/2 augments in presence of red wine poly-
phenols, but their expression drops in presence of polyphe-
nols plus LPS. This indicates that in Gram-negative infections
polyphenol may attenuate triggering of inflammatory media-
tors as a response to LPS stimulation [90]. Concerning the
well-known idea that red wine might favor anti-atherogenic
mechanisms in the course of cardiovascular disease, an
important aspect pointed out is the release of NO from
PBMC stimulated by red wine polyphenols. Release of NO
from mononuclear cells may play an important role in car-
diovascular disease, because it is known that this molecule
acts as an inhibitor of platelet aggregation [91]. Ultimately,
as previously discussed, aging is characterized by immu-
nosenescence; hence these results suggest that moderate use
of red wine may be beneficial in age-related disorders where
the host immune response is very often not effective against
a variety of antigens. Among the red wine polyphenols, res-
veratrol, chemically known as 3,4,5-trans-trihydroxy-
stilbene, is the most extensively studied. It is a phytoalexin
and has been identified in more than 70 plant species includ-
ing grapes, peanuts, fruits, red wine, and mulberries.
Resveratrol is endowed with antioxidant, anti-inflammatory
and antitumorigenic activity. Besides excellent free radical
scavenger properties, resveratrol can offer other effects to the
cell, e.g., increasing the life span by its ability to activate
G. Scapagnini et al.
sirtuins, mimicking the effects of CR [92, 93]. The multiple
roles of resveratrol as an antioxidant and as a life-promoting
agent make it an attractive candidate for treatment of age
related diseases. Resveratrol inhibits diverse cellular events
associated with tumor initiation, promotion and progression
of skin cancer and cancers of other organs [94]. It has also
antifungal and antibacterial property and seems to improve
wound healing, representing a potential molecule for the
management of diabetic people.
Curcumin is a phytochemical compound extracted from
the rhizome of Curcuma Longa, and it is the pigment respon-
sible for the curry’s characteristic yellow color [95]. It has
been used for centuries as food preservative and in the Indian
traditional medicine as a remedy for wound healing and for
treatment of various skin disorders and infections. It is a
polyphenolic substance that has the potential to inhibit lipid
peroxidation and to effectively intercept and neutralize ROS
(superoxide, peroxyl, hydroxyl radicals)18,19 and NO-based
free radicals (nitric oxide and peroxynitrite) [96]. In this
regard, curcumin has been demonstrated to be several times
more potent than vitamin E. Of particular interest is the abil-
ity of curcumin to inhibit COX-1 and COX-2 enzymes and to
reduce the activation of nuclear transcription factor NF-k®
[97]. Its anti-inflammatory properties and cancer-preventive
activities have been consistently reported using in vitro and
in vivo models of tumor initiation and promotion. In addition
to its ability to scavenge carcinogenic free radicals, curcumin
also interferes with cell growth through inhibition of protein
kinases. Although the exact mechanisms by which curcumin
promotes these effects remains to be elucidated, the electro-
philic properties of this yellow pigment appear to be an
essential component underlying its pleiotropic biological
activities. Curcumin has been recently demonstrated to
induce the activities of the Phase I and Phase II detox system,
and at low concentrations, potently induces HO-1 expression
and activity in vascular endothelial cells, in rat astrocytes and
in cultured hippocampal neurons [98, 99]. The ability of cur-
cumin to induce HO-1 can explain, at least in part, its strong
antioxidant and anti-inflammatory properties, which depend
more on its ability to activate cellular signals than on its radi-
cal scavenger effect. The involvement of curcumin in restor-
ing cellular homeostasis and rebalancing redox equilibrium
by the activation of defensive genes suggest that it might be
a useful adjunct also in AD treatment. Epidemiological stud-
ies suggested that curcumin, as one of the most prevalent
nutritional and medicinal compounds used by the Indian
population, is responsible for the significantly reduced (4.4
fold) prevalence of AD in India compared to United States
[100]. Consistent with these data, Lim and colleagues have
provided convincing evidence that dietary curcumin, given
to an Alzheimer transgenic mouse model (Tg2576) for 6
months, resulted in a suppression of indices of inflammation
and oxidative damage in the brain of these mice and to
Preventive Medicine and Healthy Longevity: Basis for Sustainable Anti-Aging Strategies
reverse A®-induced cognitive deficits [101, 102]. They also
showed that curcumin readily entered the brain to label
plaques in vivo inhibiting the formation of A® oligomers
and their toxicity. Among the several mechanisms by which
curcumin is able to clear amyloid is the induction of HSPs
that function as molecular chaperones to block protein aggre-
gate formation [103]. Recently curcumin has been evaluated
in a pilot clinical trial in AD patients; preliminary results
were encouraging [104]. Because of the anti-inflammatory
and antioxidant effect of curcumin, curcumin-supplemented
cosmetics and skin care products/lotions are available in sev-
eral parts of the world. Beyond its anti-inflammatory proper-
ties, curcumin can also inhibit some specific enzymes
involved in skin aging, such as collagenase, elastase, and
hyaluronidase, improving skin thickness and firmness.
Sulforaphane, a dietary isothiocyanate derived from broc-
coli sprouts, possesses potent chemopreventive effects
through the induction of cellular detoxifying/antioxidant
enzymes via the transcription factor nuclear factor E2-related
factor 2 (Nrf2). Topical application of sulforaphane-rich
extracts of broccoli sprouts upregulated phase 2 enzymes in
the mouse and human skin, protected against UVR-induced
inflammation and edema in mice, and reduced susceptibility
to erythema arising from narrow-band 311-nm UVR in
humans [105].
11 Physical Activity
Regular physical activity and exercise are recommended for
the maintenance of an optimal health status and the preven-
tion or management of chronic diseases (Department of
Health and Human Services, Centers for Disease Control
and Prevention, and National Center for Chronic Disease
Prevention and Health Promotion 1996). Several studies
have reported that increased physical activity can improve
mean life span presumably by reducing mortality risk from
many age-related diseases, including cardiovascular disease,
stroke, type 2 diabetes, and certain cancers [106–109]. In
contrast, exercise and longevity studies in rodents and
humans have failed to document an exercise effect on maxi-
mum life span [110]. For example, it was found in rats that
exercise improved survival compared with sedentary ad
libitum-fed controls, but did not result in life span extension.
Furthermore, when exercising rats were matched for body
weight with food-restricted paired weight sedentary rats,
only the food-restricted rats had an increase in maximum life
span [111]. However, it has been demonstrated that aerobic
exercise is able to partially reverse the typical age-associated
decline in muscle function, in particular by increasing skel-
etal muscle mitochondrial oxidative capacity, in particular
through raise in citrate synthase activity and shift of the myo-
sin heavy chain fiber type to a more oxidative phenotype
1221
[112]. In adult humans, an aerobic exercise program
improved insulin sensitivity, mitochondrial enzyme activity,
and mixed muscle protein synthesis [113]. Despite similar
enhancement of muscle mitochondrial function in response
to aerobic exercise training, younger people increased insu-
lin sensitivity more than older people, indicating dissociation
between increases in insulin sensitivity and mitochondrial
function. Aerobic exercise has been reported to enhance
muscle mitochondrial biogenesis through a calcium-
regulated signaling pathway [114]. Chronic aerobic exercise
has also been shown to stimulate 5-AMP-activated protein
kinase (AMPK) activity with subsequent increases in fatty
acid oxidation and glucose uptake in skeletal muscle [115].
There is also evidence that chronic chemical activation of
AMPK increases mitochondrial enzyme activity in selected
skeletal muscle, suggesting a possible role of AMPK in
mitochondrial biogenesis [116]. Despite the fact that such
adaptations have been analyzed for several decades, the
exact mechanism behind the effects of exercise on increasing
mitochondrial function remains incompletely defined. There
is a substantial lack of data regarding the effects of acute or
chronic exercise in aging animals or humans.
Inconsistent results (partly also due to methodological
limitations in the reactive oxygen species measurements) do
not allow a clear interpretation of studies regarding exercise-
related DNA and protein oxidation, and lipid peroxidation.
However, current literature seems to show an increased resis-
tance to oxidative damage with chronic exercise and
increased lipid, DNA or protein oxidation after an acute bout
of maximal exercise. The increased production of free radi-
cals during physical exercise has been attributed to several
factors, including the increase of catecholamines undergoing
auto-oxidation, muscle transient hypoxia and re-oxygenation,
lactic acid-induced free iron release from myoglobin, and/or
inflammation-related neutrophil function. The redox unbal-
ance is considered a possible signal mechanism activating
several genes involved in cellular stress response. The
deacetylation activity of SIRT1 in the skeletal muscle is con-
sidered to increase during exercise [117], thus suggesting
that exercise promotes the deacetylation of PGC-1α. In addi-
tion, similarly to what is seen for CR, the SIRT1 interacts
with several other proteins, and it regulates forkhead tran-
scription factors (FOXOs) transcriptional activity, which
would contribute to the expression of genes involved in fatty
acid oxidation [118]. Furthermore, a previous study demon-
strated that increased expression of SIRT1 improved the
insulin sensitivity in skeletal muscle by repressing protein-
tyrosine phosphatase 1B expression [119], a well-known
negative regulator of the insulin-signaling pathway.
Collectively, these results raise the possibility that the effect
of endurance exercise training for improving insulin
sensitivity partially results from increased SIRT1 protein
expression in skeletal muscle.
1222
12 Hormonal Therapy
Hormones are decisively involved in intrinsic aging. In
humans, there is a progressive decrease in hormone synthesis
as well as a loss of hormone receptors with age. The elderly
have demonstrated significantly lower levels of production
of most hormones compared to young adults. Over time
important circulating hormones decline due to a reduced
secretion of the pituitary, adrenal glands, and the gonads or
due to an intercurrent disease. Among them, growth factors
(i.e., growth hormone and insulin-like growth factor-I) and
sex steroids (i.e., androgens and estrogens) show significant
changes in their blood levels and play a distinct role in the
generation of the aging phenotype. Because many hormonal
levels decrease with aging, treatment with hormones has
often been called the “fountain of youth.” Much research is
needed to prove the efficacy of hormonal therapy, as data
have not demonstrated the expected positive impact of hor-
mones on aging per se [120].
In distinction to the course of reproductive aging in women
with the rapid decline in sex hormones expressed by the ces-
sation of menses, men experience a slow and continuous
decline. This decline in endocrine function involves a decrease
of testosterone, dehydro epiandrosterone (DHEA), oestro-
gens, thyroid stimulating hormone (TSH), growth hormone
(GH), IGF1, and melatonin. The decrease of sex hormones is
concomitant with a temporary increase of luteinizing hor-
mone (LH) and follicle-stimulating hormone (FSH). In addi-
tion, sex hormone binding globulins (SHBG) increase with
age resulting in further lowering the concentrations of free
biologically active androgens. These hormonal changes are
directly or indirectly associated with changes in body consti-
tution, fat distribution (visceral obesity), muscle weakness,
osteopenia, osteoporosis, urinary incontinence, loss of cogni-
tive functioning, reduction in well-being, depression, as well
as sexual dysfunction [121]. The physiological changes that
the human body undergoes during aging are similar to those
observed in GH deficiency (GHD). Early changes of aging
are represented by increased fat mass, increased cardiovascu-
lar risk, reduced muscle mass and strength, reduced exercise
tolerance, thinned skin, decreased strength and impaired
quality of life. These observations led to hypothesize that the
elderly could be GH deficient and would benefit from GH
treatment [122]. Physical changes during aging have been
considered physiologic, but there is evidence that some of
these changes are related to this decline in hormonal activity
[123]. Normal aging and GH deficiency (GHD) share several
clinical signs and symptoms: The endocrine pattern of aging
is, however, distinct from the decrease of GH and/or IGF-I
levels associated with hypopituitarism. Owing to clinical sim-
ilarities between aging and GHD, the relative GH insuffi-
ciency of elderly subjects has been postulated as one important
factor contributing to their frailty. Consequently, IGF-I levels
G. Scapagnini et al.
decline progressively: this mainly reflects the impaired GH
secretion, but decline in gonadal sex steroids and malnutrition
also play a role. Decreases in GH secretion may partially
explain the age-related changes in metabolism, bones, mus-
cles, cardiovascular system, central nervous system, the
immune system, and sense of well-being [124]. Severe GH
deficiency should be defined biochemically within an appro-
priate clinical context. An evaluation for GH deficiency
should be considered only in patients with evidence of hypo-
thalamic pituitary disease, subjects who have received cranial
irradiation, or patients with childhood onset of GH deficiency.
Patients with childhood-onset GH deficiency should be
retested as adults before committing them to long-term GH
replacement. The diagnosis of adult GH deficiency is estab-
lished by provocative testing of GH secretion. At present, the
insulin tolerance test is the diagnostic test of choice. Provided
adequate hypoglycemia is achieved, this test distinguishes
GH deficiency from the reduced GH secretion that accompa-
nies normal aging and obesity. The test is contraindicated in
patients with electrocardiographic evidence or history of
ischemic heart disease or in patients with seizure disorders.
Given these precautions, the insulin tolerance test is safe;
however, there is less experience in patients over the age of 60
years. Most normal subjects respond to insulin-induced hypo-
glycemia with a peak GH concentration of more than 5 μg/l.
Severe GH deficiency is defined by a peak GH response to
hypoglycemia of less than 3 μg/l. These cut-off values were
defined in GH assays employing polyclonal competitive
RIAs. At present, the combined administration of arginine
and GHRH is the most promising alternative. Administration
of arginine alone or glucagon alone can be considered, but
these tests have less established diagnostic value compared to
the insulin tolerance test. Other stimulatory tests may prove to
be useful, but require further validation. The present data
indicate that the clonidine test is less useful. IGF-I concentra-
tions are only useful when age-adjusted normal ranges are
available. In adults, a normal serum IGF-I does not exclude
the diagnosis of GH deficiency. A serum IGF-I below the nor-
mal range is suggestive of GH deficiency in the absence of
other conditions known to lower serum IGF-I levels. In the
presence of multiple (two or more) pituitary hormone defi-
ciencies, a low serum IGF-I level indicates a high probability
of GH deficiency. Particularly, the somatotropic response to
all provocative stimuli is negatively correlated to BMI and the
GH response in obese subjects is sometimes as impaired as
that in hypopituitary patients with severe GH deficit [125,
126]. The impairment of GH secretion as a function of over-
weight and obesity would reflect alterations in the neuroendo-
crine control of the somatotropic axis and/or metabolic
alterations such as hyperinsulinism and elevation of circulat-
ing free fatty acids [127]; reduction of GH half-life in obese
subjects has also been demonstrated [128]. Independent of
the pathophysiology of GH insufficiency due to weight
Preventive Medicine and Healthy Longevity: Basis for Sustainable Anti-Aging Strategies
excess, there is a clinical problem in the interpretation of the
GH response to provocative tests in patients suspected of
hypopituitarism and severe GH deficit, also taking into
account that adult GH deficit is often associated to weight
excess. Gasco and colleagues firstly validate the cut-off levels
of GH response to classical provocative tests by BMI level. In
this study, the authors show that in the lean population the
best pair of values, with highest sensitivity as 98.7 % and
highest specificity as 83.7 %, was found using a peak GH cut-
off point of 11.5 μg/l. In the overweight population, the best
pair of values, 96.7 and 75.5 %, respectively, was found using
a peak GH cut-off point of 8.0 μg/l. In the obese population,
the best pair of values, 93.5 and 78.3 %, respectively, was
found using a peak GH cut-off point of 4.2 μg/l [129].
The age-related decline of testosterone (T) [130], defined
as late onset hypogonadism (LOH), can occur both because
of defects at testicular or hypothalamic-pituitary functions. It
is established that T levels decrease about 1–2 % per year
after age 40 [131], and only a subset of aging men exhibit
levels clearly below the lower limit of the normal range for
healthy, young men [132]. It is estimated that hypogonadism
affects between 19 and 34 % of men over the age of 60 [133,
134]. In order to discuss the biochemical diagnosis of hypo-
gonadism, it is necessary to outline the usual carriage of T in
the blood. Serum TT consists of free testosterone (FT)
(2–3 %), testosterone bound to sex hormone binding globulin
(SHBG) (45 %), and testosterone bound to other proteins
(mainly albumin −50 %) [135]. Measuring bioavailable T, or
FT, is expensive and time-consuming, but may more accu-
rately detect hypogonadism. The normal range for serum TT
levels in early morning hours in healthy, young men, 20–40
years of age, is approximately 320–1,000 ng/dL (11–
35 nmol/L). Levels TT falling below 320 ng/dL (11 nmol/L)
or FT 70 pg/ml (0.255 nmol/L) clearly indicate hypogonad-
ism and the need for hormone replacement therapy. TT levels
between 320 and 400 ng/dL (11–14 nmol/L) should be
repeated and followed up by calculation of FT using sex-
hormone binding globulin (SHBG) concentrations or by mea-
surement of FT levels by equilibrium dialysis or bioavailable
T by the ammonium sulfate precipitation method. Treatment
for hypogonadism is usually by means of testosterone replace-
ment therapy (TRT); administration currently available are
oral, transbuccal, injectable, implants, and transdermal [136].
The so-called LOH phenomenon is important because of
the associated conditions including metabolic syndrome
[137] type 2 diabetes mellitus or impaired fasting glucose
[138], atherosclerosis [139], myocardial infarction [140],
chronic heart failure, and unwanted effects with a range of
medications [141]. Currently, low T levels are gaining recog-
nition as an independent risk factor for these conditions. In
fact, it has been demonstrated that T plays a key role in the
development of insulin resistance/metabolic syndrome (MeS)
[142], and increased risk of cardiovascular disease (CVD) as
1223
confirmed by the hypogonadal state occurring in men under-
going androgen suppression as treatment for prostate cancer
[143]. It is unclear, however, whether declines in T are pri-
marily associated with normal aging per se or rather with age-
related changes in overall health and lifestyle; but it is certain
that male hypogonadism has a multifactorial etiology that
includes genetic conditions, anatomic abnormalities, infec-
tion, neoplasm, and injury. One cause of hormone imbalance
in men is that their testosterone is increasingly converted to
estrogen. The reason that testosterone replacement therapy
does not work by itself for many men is that exogenously
administered testosterone may convert (aromatize) into even
more estrogen, thus potentially worsening the hormone
imbalance problem in aging males (i.e., too much estrogen
and not enough free testosterone). Although there are studies
that show that testosterone replacement therapy does not
increase estrogen beyond normal reference ranges, it is pos-
sible that the standard laboratory reference ranges do not
adequately address the issue of estrogen overload [144].
Therefore, in cases of endocrine deficiencies, traditional
endocrinology aims at replacing the missing hormone or hor-
mones with substitutes. Despite evidence that levels of many
hormones decline with age, additional research is needed to
prove that these declining levels are pathologic and that hor-
mone replacement actually affects the aging process.
Conclusion
A long life in a healthy, vigorous, youthful body has
always been one of humanity’s greatest dreams. The
genetic hypothesis is able to explain only about the 35 %
of the longevity in humans. In fact although all species
have a defined life span, simple modifications of the envi-
ronment can substantially affect organismal longevity.
According to De Grey, recent progress in genetic manipu-
lations and calorie-restricted diets in laboratory animals
hold forth the promise that someday science should
enable us to exert total control over own biological aging.
To conclude, at present, aging must be considered an
unavoidable end point of the life history of each individ-
ual. Nevertheless increasing knowledge about the mecha-
nisms regulating aging allows us to envision many
different strategies to delay the onset of age-related dis-
eases, in order to endow everybody with a long and good
final time in life.
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 Anti-Aging: An Overview
Alfred P. Yoon, Stephen P. Daane, Bryant A. Toth,
and Ina A. Nevdakh
1 Introduction
Although the masterminds of humanity (Michelangelo,
Goethe, Picasso, and Newton) all lived past 80 years of age
and led productive lives without the help of modern medi-
cine [1], human life expectancy only recently increased from
47 years in 1900 to 80 years in 2000. The U.S. Census
Bureau projects [2] that by 2040 a minimum of 1.3 million
people would reach the age of 100. We have gained more
years in life expectancy in the recent century than the dawn
of mankind, likely due to improvements in medical technol-
ogy, sanitation, and vaccinations. With or without the help of
medicine, the maximum average life span of a human being
has been projected to be between 85 and 95 years. Several
theories have been proposed to explain the biological mecha-
nism of aging, but among these the “telomere hypothesis”
that originated about 40 years ago has continued to gain sup-
port through research: This theory suggests that cellular
aging occurs due to a loss of telomeric DNA due to incom-
plete replication or degradation of DNA ends. When a cer-
tain length of telomere is reached, the cell evokes the
Hayflick limit and stops cell division [3].
Throughout the nineteenth century, the esteem and respect
held for old age disappeared and senescence was chal-
lenged by “scientific” discoveries – aging became a disease.
A.P. Yoon, BS
Bioengineering Department, Lawrence Berkeley National
Laboratory, Berkeley, CA, USA
S.P. Daane, MD
Private Practice, San Francisco and San Ramon, CA, USA
B.A. Toth, MD, FACS (*)
Private Practice, Toth Plastic Surgery, San Francisco, CA, USA
Clinical Professor of Surgery, University of California,
San Francisco, CA, USA
e-mail: tothbryant@gmail.com
I.A. Nevdakh, MD
Department of Plastic Surgery, Oregon Health Sciences University,
Portland, OR, USA
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_83
Companies such as Cenegenics emerged to advertise antiag-
ing therapy as a combination of diet, exercise, supplements,
and hormones [4]. However, what follows is the “state of the
art” in antiaging medicine in 2012, based on scientific and
clinical research.
2 Conventional Approach
2.1 Caloric Restriction
The only established method of aging retardation is caloric
restriction, or “undernutrition” without malnutrition [5]. This
method also seems to delay the onset of age-related diseases
and maintain youthful physiologic functions [5]. From previous
experiments done with animals including small mammals,
caloric restriction increases insulin sensitivity and life span [6,
7]. A recent 2-year experiment supplying Rhesus monkeys with
a 30 % caloric restriction has shown an average core tempera-
ture decrease of 0.5 °C compared to a control group [8]. This
result parallels the body temperature decrease seen in rodents
who underwent caloric reduction and eventually achieved an
increase in longevity [5]. Hence, the body temperature reduc-
tion in Rhesus monkeys could signify a potential increased life
span in nonhuman primates as observed in rodents.
Several theories have been proposed to explain the effect
of caloric restriction on longevity. One theory claims the
activation of autophagy in times of nutrient shortage might
be correlated with the antiaging effect of caloric restriction
[9]. Another study indicates that ad libitum-fed rodents may
have less sensitive mammalian cells to hormones, and
caloric restriction might prevent these changes [10]. Insulin
and glucagon are two main hormones that regulate autoph-
agy; however, the regulation imposed by these hormones
seemed to be lost in aging cells. Caloric restriction was able
to moderate the age-dependent loss in autophagy regulation
by glucagon and insulin [11]. A third theory is that caloric
restriction help stimulate heat shock proteins (Hsps) and
1229
1230
protect cells and organs from stress. An attenuated response
to stress is a characteristic of senescence [12]. Colotti et al.
[12] showed that an aging rat heart shows decreasing levels
of Hsp27, Hsp60, Hsp72, and Hsc70 in the right atrium and
left ventricle. The last theory advances the possibility of
caloric reduction decreasing oxidative stress by attenuating
upregulated age-related factors such as nuclear factor kappa-
light-chain enhancer of activated B cell (NF-|B),
Interleukin-1 beta (IL-1®), Interleukin 6 (IL-6), Tumor
Necrosis Factor-alpha (TNF-α), cyclooxygenase-2, and
inducible nitric oxide synthase [13].
2.2 Antioxidants
The free radical theory including antioxidants is another
mainstream theory of aging. Oxygen radicals occur within
cellular organelles as natural by-products of cellular func-
tion [14]. These reactive species cause oxidative damage to
target molecules of mitochondria and lysosomes located in
the heart, liver, and pancreatic beta cells [14]. Antioxidants
assist other enzymes such as superoxide dismutase in the
body to prevent reactive species from damaging cellular
structures. In the human body, iron is an important source of
the potent antioxidant bilirubin Ix໭ [15]. The primary source
of cellular iron is heme iron [15]. The heme oxygenase
isozymes HO-1 and HO-2 degrade the heme irons isomer
specifically into one molecule of CO and biliverdin. Then,
biliverdin is almost immediately converted to bilirubin Ix໭
by biliverdin reductase [15]. Free radical oxygen inactivates
bilirubin and deprives the cell of its natural antioxidant
[16]. Deficiency of antioxidants or other nutrients prevent
the correct intermediaries from forming during heme bio-
synthesis, resulting in an accumulation of oxygen-reactive
species that cause cellular damage [17]. However, 15 clini-
cal trials including antioxidants such as tocopherol, beta-
carotene, vitamin C, vitamin E, retinol, and folic acid have
been conducted and none has shown a statistically signifi-
cant effect on aging [18].
2.3 Lycium barbarum (Wolfberry)
Lycium barbarum is a common ingredient in oriental medi-
cine and is known for nourishing the liver and improving
eyesight [19]. Polysaccharides extracted from L. barbarum
can protect neurons against beta-amyloid damage in cell
cultures. Also, the polysaccharides may have antiaging, anti-
tumor, neuro-modulation, and immune modulation effects.
From experiments in which D-galactose was injected into
mice, L. barbarum attenuated the oxidative stress result-
ing from metabolism and nonenzymatic glycosylation of
D-galactose. L. barbarum seemed to return the decreased
A.P. Yoon et al.
interleukin-2 levels to normal [19]. The polysaccharide,
LBP, from L. barbarum seemed to restore motor activity,
memory index, and increase superoxide dismutase levels in
erythrocytes when fed to mice 100 mg/kg daily [20]. The tar-
get tissues of LBP seem to vary and have effects in protect-
ing cells from hyperglycemia, oxidation, and hyperlipidemia
conditions [19].
3 The Modern Approach
3.1 Testosterone
Male aging is accompanied by a gradual decline of serum
testosterone levels. These levels of decrease differ on an
individual basis. With the decline of testosterone, symp-
toms such as decrease in muscle mass and strength, cog-
nitive decline, lowered bone density, and an increase in
adipose tissue in the abdominal region arise [21]. Because
of this correlation, interest in using sex hormones, espe-
cially testosterone, has developed in recent years for antiag-
ing therapy [22]. Various clinical trials have mixed findings
on the effects of testosterone, most likely due to differ-
ences in experimental design, overall health of subjects, and
gonadal status [23–26]. One of the more recent compre-
hensive experiments published in the Journal of American
Medical Association by Emmelot-Vonk et al. [22] explores
the physiological effects of testosterone in old age. A dou-
ble-blind, randomized, placebo control of 237 healthy men
between 60 and 80 were conducted over a 15 month period
[22]. These subjects had testosterone levels lower than
13.7 nmol/L [22]. The control group and the variable group
supplemented with testosterone had no significant differ-
ence in muscle strength, bone density, or cognitive abilities
[22], but the variable group did experience an increase in
lean body mass and decrease in body fat mass as well as
body fat percentage [22]. This led to an increase in insulin
sensitivity and decreased glucose levels [22]. A significant
decrease in both total and HDL cholesterol were seen in the
variable group [22], as well as a marked increase in total
cholesterol to HDL ratio [22]. Triglycerides and low density
protein had negligible change [22]. Metabolic syndromes
such as coronary artery diseases and strokes increased more
in the testosterone group than the control group most likely
due to the decrease in HDL cholesterol [22]. Prostate vol-
ume and Prostate Specific Antigen (PSA) levels were not
changed significantly in either group [22]. From this study,
it can be assumed that testosterone is not a scientifically
reliable source of antiaging medicine and can lead to side
effects. More research and studies must be done to conclu-
sively state the physiological impact of supplemental testos-
terone on the human body.
Anti-Aging: An Overview
3.2 DHEA (Dehydroepiandrosterone)
Steroid
DHEA is a naturally produced hormone that can become the
precursor of testosterone or estrogens. Mature adrenal
glands and gonadal glands produce many steroid hormones
using the steroidogenic enzyme cytochrome P450 [27].
Among them, dehydroepiandrosterone sulfate (DHEA-S)
seemed to hold some promise in antiaging [27]. Cytochrome
P450c17 has two enzymatic activities, 17-໭-hydroxylase and
17, 20-lyase. Cortisol is synthesized by the former and
DHEA is synthesized by the latter [27]. Plasma concentra-
tions of DHEA start increasing during adrenarche and peak
at puberty. Then, DHEA linearly decreases with a person’s
age [27]. DHEA production depends on other regulators of
17,20-lyase such as cytochrome b5, P450 reductase, and
adrenal lipid peroxidation [28]. The cytochrome P450
reductase activity significantly decreases in aged adrenal
glands compared to younger ones, but P450b5 stays con-
stant with age [27]. This results in a decrease in DHEA syn-
thesis without a change in cortisol levels with age [27].
According to experiments with mice, DHEA has anti-obe-
sity, anti-diabetic, anti-atherosclerosis and anti-osteoporosis
effect [27]. However, a more recently conducted 2-year
double-blind experiment in 2006 by Nair et al. [29] suggests
that DHEA does not seem to have any significant effect on
human muscle strength, insulin sensitivity, or oxygen con-
sumption rate.
3.3 Human Growth Hormone (GH)
Human growth hormone levels are high early in life, corre-
sponding to somatic growth, but decrease soon after physical
and sexual maturation [30]. Age-related decline in GH levels
are well known and primarily due to reduced hypothalamic
secretion of GH-releasing hormone (GHRH) with decline in
GH biosynthesis and release by the anterior pituitary [31–
34]. This decline leads to a decrease in circulating levels of
insulin-like growth factor-1 (IGF-1), the key mediator of GH
action [35, 36]. In a study by Rudman et al. [37] in 1990, the
administration of GH for 6 months increased lean body mass
(8.8 %), decreased adipose-tissue mass (14.4 %), increased
lumbar vertebral bone density (1.6 %), and increased skin
thickness (7.1 %). Papadakis et al. [38] showed a 4.3 %
increase in lean body mass and a 13.1 % decrease in fat mass
in a group of elderly men after 6 months of GH treatment;
however, they failed to demonstrate any change in muscle
strength. Unlike GH treatment in GH-deficient adults, the
treatment on adults over 60 years old resulted in an insignifi-
cant increase in bone mineral density after 1 year of GH
treatment [37]. In addition, subsequent studies indicated that
normally healthy elderly individuals with human growth
1231
hormone produced small improvements in the body compo-
sition with a number of side effects such as carpal tunnel
syndrome, insulin resistance, edema, and arthralgia [38–40].
The most concerning side effect of GH is the relation between
IGF-1 levels and cancer [41]. Subjects with elevated IGF-1
levels have a significantly augmented risk of developing
malignant cancer later in life, as seen from the raised occur-
rence of prostate cancer in men over 60 who have IGF-1 lev-
els higher than 75 % of the population [41]. Thus, it seems to
be difficult to reproduce the therapeutic results achieved
from irradiating or treating young or middle-aged adults who
develop GH deficiency as a result of injury or disease in
elders who lose GH levels due to somatopause [30].
Studies in mice suggest that mice with mutations which
cause GH deficiency or GH resistance live longer than their
counterparts that have normal GH levels [42, 43]. The muta-
tions in these animals range from mice with suppressed GH
genes that produce complete GH resistance to mice with GH
deficiency due to a mutation in the receptor for hypothalamic
GH-releasing hormone [42, 43]. The amount of increase in
longevity in these mice is astounding: 25 % to over 60 %
compared to mice with normal GH levels [42, 44–46]. Most
importantly, these long-lived mutant rodents display vigor
and cognitive abilities in ages when these animals normally
display significant decline in function and vitality [43, 47,
48]. If these effects on mice are applicable to humans, subtle
and long-term reduction in GH release and/or activity may
retard the aging process [30]. However, the symptoms of
congenital or acquired GH-deficiency warn against severe or
complete suppression of GH for human longevity [30].
Increasingly, experimental data indicates that men and
women over 60 are not GH deficient. Comparison of 24
healthy adults with 24 patients with pituitary disease, all over
60 years old, indicated that the latter have significantly
decreased levels of GH secretion [49]. Lastly, the clinical use
of GH is only approved for treatments of idiopathic short
stature, GH deficiency, and HIV/AIDS in the US [30]. The
counterintuitive results obtained from mice GH experiments
as well as the many known undesirable side effects seem to
indicate that GH supplementation is currently not a reliable
approach to antiaging.
3.4 Klotho
With an effort to locate the gene or genes that determine the
aging process, scientists have discovered an aging suppres-
sor gene that increases longevity when overexpressed in
mice. Klotho is a gene that increases resistance to oxidative
stress in cells and organs by activating FoxO forkhead tran-
scriptional factors that are negatively regulated by insulin/
IGF-1 signaling [50]. FoxO transcriptional factors have
gained attention in current research regarding antiaging due
1232
to its role in atrophy, autophagy, apoptosis, cell cycle arrest,
stress resistance, gluconeogenesis, and many other functions
inside the cell [51]. A defect in the klotho gene in mice lead
to symptoms akin to human aging: shortened life span, infer-
tility, growth arrest, hypoactivity, and skin atrophy [52]. The
klotho gene encodes for a type of transmembrane protein
only expressed in the distal convoluted tubules of the kidney
and the choroid plexus in the brain [52]. The extracellular
domain of the Klotho protein is shed into the bloodstream
and binds to an unidentified Klotho receptor [50]. This pro-
tein is a hormone that inhibits the intracellular insulin/IGF-1
signaling cascade, which most likely increases life span [50].
It has been suggested that single nucleotide polymorphisms
in the human klotho gene are related to longevity, age-related
disease, and stroke [53–55].
3.5 Metformin
Metformin is the commonly used anti-diabetic biguanide
that increases insulin sensitivity. Studies in mammals have
shown that hyperglycemia and hyperinsulinemia are contrib-
uting factors to aging and cancer development [56]. Because
of these findings, anti-diabetic drugs such as metformin have
become candidates as potential antiaging agents. In various
studies, this drug has been shown to extend the life span of
rodents [56, 57]. Metformin treatments resulted in inhibi-
tion of mammary tumor development in mice and increased
their latency, which could be a possible cause of increase in
life span [56]. Anti-diabetic biguanides, such as metformin,
increase the sensitivity of the hypothalamus and pituitary
gland to negative feedback inhibition [57]. Another experi-
ment done on the rat soleus and red and white gastrocnemius
muscles also suggests that biguanide enhances the peroxi-
some proliferator-activated receptor-© coactivator-1໭ (PGC-
1໭) [58]. PGC-1໭ is a central coactivator that regulates cellular
metabolism. In addition to the increase in PGC-1໭, metfor-
min induced an augmentation of citrate synthase activity in
all three muscles, hexokinase activity in white gastrocne-
mius, and ®-hydroxyacyl-CoA dehydrogenase activity in the
soleus [58]. The mechanism in which metformin achieves
these effects is suggested to involve the enhancement of the
AMP-activated protein kinase (AMPK) pathway [58]. Based
on these experimental findings, metformin seems to be a
promising candidate for muscle activity restoration.
3.6 Rapamycin
A natural antifungal antibiotic in low nanomolar concen-
trations, rapamycin selectively inhibits the mammalian tar-
get mTOR [59]. Rapamycin is commonly used after renal
A.P. Yoon et al.
transplantation to prevent organ rejection but no immuno-
suppressive problems have been observed from its use [60].
The mammalian target of rapamycin is an evolutionarily
conserved protein kinase pathway that controls cell prolif-
eration, growth, and survival [59, 61]. Since it is evolution-
arily conserved, its effects can be equally potent in a yeast
cell or a human cell [59]. Rapamycin is antagonistically
pleiotropic since it decelerates both yeast senescence and
yeast growth [59]. But developmental growth is not neces-
sary later in life which makes rapamycin an ideal candi-
date for antiaging medicine [59]. Rapamycin has also been
known to prevent tumors and osteoporosis while increas-
ing blood lipids such as triglycerides resulting in hyperlip-
idemia and hypertriglyceridemia [60, 62]. In addition, it
also increases adipose tissue lipase activity, driving lipids
from fat tissue to blood, preventing lipid accumulation on
vascular walls [63]. Senescent cells are hypertrophic and
this can be connected to the symptoms of aging such as
wrinkles and prostate enlargement in men [64]. The most
notable feature of cell senescence [59] is cell cycle arrest
and relates to telomeres, p53, p16, and p21. In a normal
cell, mitogens activate the Raf-1/MEK/ERK and phosphati-
dylinositol 3-kinase (PI3K)/Akt kinase signaling pathways
[59]. Subsequently, these pathways activate mTOR, stimu-
lating cell growth and protein synthesis [65]. In addition, the
Raf-1/MEK/ERK and PI3K/Akt kinase pathways govern the
cell cycle, allowing cell division; hence, a balance of growth
and division is achieved [66]. On the contrary, in senescent
cells, this balance in disrupted by a blocked cell cycle and
an active growth-promoting pathway [64]. Experiments
on various organisms including Caenorhabditis elegans,
Saccharomyces cerevisiae (yeast), and Drosophila melano-
gaster showed mutation or inhibition of the mTOR pathway
increased life span [59]. As previously mentioned, reduced
insulin/IGF-1 signaling and increased sensitivity to insu-
lin are associated with longevity in small mammals [6, 7].
Insulin sensitivity and IGF-1 signaling have similar effects
with human longevity as well [67]. Insulin sensitivity is a
marker of genetically reduced mTOR activity since mTOR
causes insulin resistance [68]. Inhibiting cell growth and
increasing insulin sensitivity, rapamycin is a nontoxic and
well-tolerated drug that holds promise to antiaging.
3.7 Sirtuin Activators
Some researchers propose that calorie restriction extends the
replicative life span of yeast by increasing the activity of
Sir2, a member of the conserved sirtuin family of NAD(+)
dependent protein deacetylases [69]. The homolog of Sir2 in
humans is the SIRT1, a gene that codes for human deacety-
lase [69]. It has also been suggested that relevant activities of
Anti-Aging: An Overview
Sir2-like deacetylases might be more complicated in higher
eukaryotes as seen from its opposite effects on chronological
life span compared to those on replicative life span [69]. The
SIR2 enzymes coded by the Sir2 gene play an important role
in regulating cellular activities such as DNA repair, rDNA
recombination, and aging in model organisms [70]. The
mechanisms of SIR2’s effect in mammalian cells are still
ambiguous, but recent studies have shown that SIR2 partakes
in regulating apoptosis and cell differentiation [71].
NAD-dependent deacetylase sirtuin-1 in mammals is the
protein encoded by the SIRT1 gene. The nonhistone cellular
substrates of sirtuin 1 includes tumor suppressor p53, tran-
scriptional factor NF-|B, and the FoxO family of transcrip-
tional factors, which are all crucial factors in cell survival
and longevity [72]. Sirtuin 1 substrates have been suggested
to have roles that link energy metabolism and nutrient avail-
ability, which could relate to cell survival [73]. Various fields
of medicine including gerontology and oncology are explor-
ing sirtuins because of their roles as longevity factors in sev-
eral model organisms [73]. A possible mechanism for SIRT1
is that it seems to antagonize the mammalian target of
rapamycin (mTOR) pathway downstream to mTOR [74]. A
known target of sirtuin 1 is lysine 382 of p53 [75–77].
Deacetylation of this residue by sirtuin 1 reduces the half-life
of p53 and decreases its activity while increasing cell sur-
vival under various DNA damaging conditions [75–77].
Julien et al. [78] showed a significant decrease in sirtuin 1
protein and mRNA in the context of patients with Alzheimer’s
disease, but the role of sirtuin 1 in neurological pathway is
still unknown.
3.8 Resveratrol
Resveratrol is a polyphenol found in red wine and is known
to extend life span in fish, yeast, and mice [79–81]. Recent
investigations suggest that resveratrol is one of the most
potent instigators of SIR2 activity among all the plant poly-
phenols [82]. Research evidence shows an increased life
span in yeast after treatments with resveratrol through acti-
vation of SIRs [83]. The popular notion of red wine con-
sumption and longevity seems to gain support through this
research [83], but studies in yeast used much higher con-
centrations of resveratrol than that found in consumption
of red wine [82], and the bioavailability of resveratrol after
metabolism inside the human body is very low since all phe-
nolic compounds undergo rapid clearance from the plasma
[82]. In addition, correlation of red wine and human lon-
gevity has still not been conclusively proven [82]. Recently,
Wood et al. [84] showed SIR activation in metazoans with
resveratrol with an extended life span. This research sug-
gests that resveratrol influences longevity through similar
1233
mechanisms as seen in calorie restriction. Moreover, Bauer
et al. [85] demonstrated that resveratrol extends fly life
span under normal laboratory conditions through studies of
Drosophila melanogastor. Howitz et al. [79] conducted fluo-
rescent deacetylation assays on human SIRT1 and found out
that resveratrol stimulated SIRT1 at relatively low concen-
trations (0.5 ໤M), but at high doses (50 ໤M) it had the oppo-
site effect. Even though resveratrol is shown to influence the
SIRT1 gene, several theories exist regarding the mechanism
of its effects. One theory postulates that resveratrol might
be an antioxidant, in line with the free radical theory [82].
Another theory suggests that resveratrol is an indirect inhib-
itor of the mTOR pathway: It activates AMPK and induces
PGC-1໭ like metformin [58]. The third theory states that
resveratrol downregulates inflammatory responses through
inhibition of the synthesis and release of pro-inflammatory
mediators. Furthermore, it proposes that resveratrol inhibits
activated immune cells and restrict inducible nitric oxide
synthase (iNOS) and cyclooxygenase-2 (COX-2) by attenu-
ating NF-|B or the activator protein (AP-1) [82].
3.9 Melatonin
Melatonin is an indolamine that is produced and secreted by
the pineal gland [86]. Melatonin levels are monitored by the
hypothalamic suprachiasmatic nucleus (SCN) and vary with
the circadian rhythm: highest during night time and lower
during day time [87]. One of the properties of melatonin is
its hypnotic effect, which seems to be mediated by reduc-
ing body temperature [88]. Melatonin determines the qual-
ity of sleep and the speed of falling asleep, which are both
problematic aspects of old age [88]. Various research studies
have shown that melatonin confers a free radical eliminating
effect [89], protection again oxidative stress [90], immuno-
enhancing effects, protection from cytotoxic apoptosis [91,
92], and prevention of induced tumors [93]. Progressive low-
ering of nocturnal melatonin secretion peaks are observed
with increased age, but this can be attributed to either a
decrease in secretion of melatonin or decrease in sensitiv-
ity and/or the number of noradrenergic receptors [94]. Even
though decreasing melatonin levels are observed with old age,
the physiological circadian periodicity of melatonin secre-
tion is maintained in centenarians [94]. Several clinical stud-
ies have shown that patients with Alzheimer’s disease show
decreased levels of melatonin [86]; melatonin seems to have
neuroprotective effects against the neurotoxic Amyloid-®
protein [86]. In addition, experiments with cultured neurons
in vitro show that melatonin is capable of upregulating sir-
tuin 1 protein levels in aged primary neurons [73]. Treatment
with melatonin decreased the acetylation levels of SIRT1
substrates such as p53, NF-|B, PGC-1໭, and FoxO1 in aged
1234
primary neurons [73]. Several experiments seem to indicate
that caloric reduction increases the production of melatonin
inside the gastrointestinal tract [1]. Food-restricted mice had
nighttime melatonin levels twice as high as the ones fed ad
libitum [95, 96]. The number of adrenergic receptors in the
pineal gland was twice as high in mice with calorie restric-
tion as that of the controls [97]. Addition of melatonin to the
drinking water of aged rats resulted in nocturnal concentra-
tion of melatonin similar to that of younger rats [98]. The
aged rats were restored to reduced intra-abdominal fat lev-
els, reduced non-fasted plasma insulin and leptin, and stimu-
lated investigative behaviors [98]. In various studies, chronic
nighttime administration of melatonin increased life span
as well as improved immunocompetence, increased thymus
weight, and elevated blood concentration of testosterone and
thyroid hormones [99, 100]. From recent studies, increasing
evidence advocates that the gastrointestinal tract is another
major source of melatonin in addition to the pineal gland:
The enterochromaffin cells of the GI mucosa are most likely
where melatonin is produced [101]. However, it has not been
established whether an age-dependent decrease of melatonin
occurs inside the gastrointestinal tract as well [1].
Several theories exist that address the mechanism of mel-
atonin’s effects on the aging process [1]. The first is that
melatonin rhythm deteriorates with aging and other rhythms
in the body become desynchronized, which might contribute
to old age diseases [1]. Another prominent theory is that
melatonin could attenuate DNA and other macromolecules
in the body from free radical damage; therefore, melatonin
might prevent aging by protection against free radical dam-
age [89, 102]. The last theory is that melatonin might play a
role in preventing neurodegenerative disease [103]. In exper-
imental animal cells with Alzheimer’s disease, melatonin
reduced beta amyloid (Amyloid-®) or prevented cell deaths
[103]. It also reduced oxidative damage to the brain in
patients with Parkinson’s disease [1]. Despite all these exper-
iments uncovering the potential benefits of melatonin, some
evidence suggests that melatonin can increase the incidence
and life span of tumors. Anisimov et al. discovered that
tumors persist for a longer period of time in female mice
when exposed to melatonin [104, 105].
Conclusion
When President Lyndon B. Johnson signed the Social
Security Act of 1965, the first Medicare program was cre-
ated in the United States. At this time, Americans retired at
55 and life expectancy was 70 years. Now, Americans
retire at an age of 65 (or older) and are expected to live
until age 80. Antiaging science endeavors to increase not
only human longevity, but also the quality of life in older
ages so people can retain their memory, physique, and
independence. Although the development of potential
therapies in antiaging medicine is exciting, science is still
A.P. Yoon et al.
a long way from developing an all-encompassing antiag-
ing “pill.” In addition, clinical trials of such drugs in
humans would require whole lifetimes, making it
extremely difficult to conduct meaningful experiments.
State-of-the-art research is being conducted to unravel the
secrets to the fountain of youth. However, even though the
experimental compounds cited above have yielded many
promising insights, many of the key targets these mole-
cules act upon have not been identified. In 2012, we are
still far from understanding the side effects and conclusive
mechanisms of these substances inside the human body.
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Drug Dev Res 56(3):482–490
 Aesthetic Regenerative Surgery
Claudio Calabrese, Tulc Tiryaki, N. Findikli, and D. Tiryaki
1 Tissue Engineering in Aesthetic
Plastic Surgery
1.1 General Overview
There is little debate about the fact that tissue engineering is
one of the most important emerging fields of twenty-first
century medicine. Henceforth, there are two important ques-
tions to be answered for specialists that are dealing with aes-
thetic problems of human body. The first one is whether
there is a role for them in this emerging field and second
whether there is a significant use of these new techniques in
aesthetic and/or reconstructive practices.
Owing to two recent advancements, first the recognition
of fat tissue as the most important source of stem cells in
human body, and second, the development of relatively sim-
ple techniques of isolating these stem cells from fat, plastic
surgeons might emerge as the specific group who can harvest
stem cells in abundance without the need of expanding them
for weeks in expensive facilities and provide the other spe-
cialties with this never-ending regenerative power. Indeed, it
is in our reach today to harvest nearly as many mesenchymal
stem cells as needed at the bedside. Our quest today is to
determine whether tissue engineering is providing us with
any advantage compared to our traditional treatment
modalities.
Only in USA millions of people are under treatment
because of congenital (i.e. lipodystrophies) and traumatic
C. Calabrese, MD (*)
U.O.S. di Chirurgia Oncologica e Rigenerativa, Breast Unit,
Azienda Ospedaliero Universitaria Careggi, Florence, Italy
e-mail: c.cal@iol.it
T. Tiryaki, MD
Cellest Plastic Surgery, Altzeren sk 5, Levent, Istanbul, Turkey
N. Findikli, MD
Department of Tissue Engineering, Yildiz Technical University,
Istanbul, Turkey
D. Tiryaki, MD
Department of Biophysics, Yeniyuzyll University, Istanbul, Turkey
© Springer Berlin Heidelberg 2016
N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8_84
(accidents, extensive deep burns, etc.) tissue deficiencies or
removal of tumours varying from small resections to mastec-
tomies after breast cancer. Approximately eight million
operations are being performed for this reason and this num-
ber is increasing annually. The goal of tissue engineering
might be described as making “replacement parts” for
patients who have sustained loss or damage to body parts
through disease or injury. Aging on the other hand is another
topic affecting the whole population of the world. Although
our knowledge and ability to treat these problems increase
every day, no ideal material to treat the major problems of
skin and soft tissue aging has been found yet.
Contemporary tissue engineering applications consist of
four main components:
1. Scaffolds (biomaterials)
2. Growth factors/hormones
3. Genetic manipulation (if required)
4. Cells of various origin and function
In plastic surgery, so far, numerous biomaterials have been
produced and effectively utilized for soft tissue augmentation
with variable results in clinical setting [1]. Although natural
scaffolds like collagen, elastine, etc., and synthetic ones, such
as polyethylene, polypropylene have been described in the
literature, still for the spectrum of treatments plastic surgeons
are using, two promising scaffolds, namely fat tissue and
hyaluronic acid, are below at the agenda. Regarding growth
factors, numerous studies have so far been conducted focus-
ing mainly on adipogenic induction and neovasculogenesis.
For studies that include cellular components, a clear advan-
tage of using adipogenic induction before transplantation has
been demonstrated [2]. In clinical setting however, the most
commonly and actively used method of growth factor appli-
cation is the utilization of autologous platelet rich plasma
(PRP). Platelets have long been known as a great source of
growth factors such as PDGF, VEGF, and these factors may
interfere with the ischemic environment of the graft by pro-
ducing cytokines that facilitate wound healing and neoangio-
genesis [3]. It is also known that VEGF is released from
1239
1240
platelets during blood clotting; hence, combination of fat
grafts and PRP may provide a timed release of VEGF in the
postoperative period. A positive effect of combining PRP
with a natural scaffold and cells has also been recently dem-
onstrated [4]. On the other hand, although PRP holds prom-
ise, more studies are needed to show the real impact of adding
PRP to fat grafts [3, 5].
As one of the major components of contemporary tissue
engineering applications, gene therapy has recently emerged
as a very promising and powerful approach for bone repair
that overcomes limitations of protein-based therapy. Several
preclinical studies have shown that gene transfer technology
has the ability to deliver osteogenic molecules to precise ana-
tomical locations at therapeutic levels for sustained periods
of time. On the other hand, in current clinical practice, genet-
ically modified cells or any biological material that contains
genetically modified cellular component cannot be eligible
for therapeutic applications on humans.
In plastic surgery applications, a variety of adult differen-
tiated cells such as autologous fibroblasts, keratinocytes,
chondrocytes and osteoblasts have so far been utilized [6–8].
According to the current literature, unless combined with a
suitable scaffold, autologous cells on the other hand mostly
fail to be retained around the injected area and are less per-
sistent at the transplanted region.
1.2 Utilization of Autologous Fat for Tissue
Repair
The first who published data regarding the use of autologous
fat transplantation in 1893 was Neuber, who filled scars with
autologous fat and found a significant reduction of transplant
size presumably due to insufficient vascularity and cell
death. Later, Peer [9] published his results on fat grafting,
indicating that retention rates of the grafts are very unpre-
dictable and usually not more than 50 %. Several studies
after these initial landmarks also indicated a variable absorp-
tion rate ranging from 20 to 90 % [10–12]. Recently, the
microinjection technique dramatically improved the survival
of transplanted fat.
Nowadays, autologous fat transplantation can be consid-
ered as an ideal treatment for facial rejuvenation and soft
tissue augmentation as it provides “like for like” tissue mate-
rial and results in no incisional scar or complications associ-
ated with foreign materials [1]. In fact, successful usage of
fat transplantation for various soft tissue defects as well as
facial volume replacement and rejuvenation has been widely
described in the literature [12–16]. However, certain limita-
tions remain, such as unpredictability and a variable rate of
graft survival believed due in part to partial necrosis espe-
cially in injection areas where the circulation and wound
healing capacity is impaired by previous fibrosis due to
C. Calabrese et al.
surgery, injections, radiotherapy or any other acquired
pathology. Many steps to overcome these problems have
been reported from meticulous harvesting, to injection tech-
niques like lipostructuring and lipo-layering [17–19]. One
recent innovation is the enrichment of the transplant with
autologous mesenchymal stem cells harvested from the fat.
These pros, cons and limitations of traditional fat trans-
plantation lead us to the usage of adipose-derived regenera-
tive cells (ADRCs).
1.3 Utilization of Adipose-Derived Stem/
Regenerative Cells for Tissue Repair
Currently, there exists a growing scientific as well as clinical
interest regarding the potential of stem cells to use them in
wide therapeutic approaches. Numerous sources of stem
cells have recently been determined in the adult including
bone marrow, fat, muscle, liver, skin, heart, brain and also
fetal and embryonic tissues. Among them, due to their
unlimited self-renewal and proliferation capacity as well as
the ability to differentiate into variety of different cell types
(of mainly mesodermal origin such as osteoblasts, chondro-
blasts, myocytes, and adipocytes), mesenchymal stem cells
(MSC) are considered to have the highest clinical potential
for the cell-based therapeutics.
Except cord blood, primary source of mesenchymal stem
cells have been adult tissues and organs. Some scientists
therefore argue that mesenchymal stem cells isolated from
adult donors are also aged and their quality, proliferation,
differentiation and hence therapeutic capacity can be
decreased with age [20, 21]. This may seem to promote the
utilization of younger stem cell types such as embryonic and
fetal stem cells. However, the ethical as well as biological
dilemma and limitations of embryonic and fetal stem cells
nowadays keep them away from being utilized as stem cell
sources for cell-based therapeutics [22].
Recent developments on the isolation, characterization,
culture expansion and differentiation of MSCs indicate that
bone marrow and adipose-derived adult stem cells stand for
the most potential source of cells for plastic surgery. Bone
marrow has long been determined to hold a significant popu-
lation of stem cells that have regenerative potential.
Therapeutic potential of bone marrow–derived MSCs to
repair and regenerate bone, cartilage, adipose, heart and even
neuronal tissues has already been shown by many groups
worldwide [23]. However, donor-site issues including pain
and morbidity as well as the quantity of cells that can be
harvested are two major limitations of using these cells for
therapy. As quantity of the cells collected from the bone
marrow is not adequate for therapeutic use, Good
Manufacturing Practice (GMP)-regulated tissue processing
facilities are generally needed to expand and enrich the stem
Aesthetic Regenerative Surgery
cell population in question [24, 25]. However, stem cell
expansion process is relatively expensive, heavily regulated
and can create a risk of phenotypic as well as genotypic
changes in the biology of the cells.
On the other hand, similar to bone marrow, adipose tissue
is also derived from the embryonic mesenchyme and rapidly
expands after birth by proliferation of the adipocyte precur-
sor cells. Also like bone marrow, fibroblast-like cells in adi-
pose tissue contain a population of cells that can differentiate
toward a number of derivations not limited to the osteogenic,
myogenic, chondrogenic, adipogenic and neurogenic deriva-
tions [26]. These heterogenic population of precursor cells,
also termed as “Adipose-Derived Regenerative Cells
(ADRCs)” are thought to play a major role in the adipose
tissue homeostasis. After the initial report published by Zuk
and her colleagues, our knowledge on the isolation, charac-
terization, differentiation as well as therapeutic potential of
adipose-derived stem cells on certain disease models have
been expanded enormously [26]. Ironically, although aes-
thetic surgery is the primary source for nearly all ADRC
derivation reports published so far, the possible therapeutic
applications of ADRC on plastic and aesthetic surgery have
just recently been considered [23, 27, 28].
ADRCs have been isolated from the samples that have
been obtained either after liposuction or excision of the fat
tissue during aesthetic or reconstructive surgery. It is now
generally accepted that, compared to bone marrow counter-
part, properties such as being easily harvested, available in
larger amounts and being rich in heterologous progenitor cell
populations, the use of adipose tissue as a stem cell source
accumulates wider interest in cell-based therapeutic applica-
tions [29]. Moreover, it has recently been shown that adipose
tissue contains ×102 to ×103 times more pluripotent cells on
a per cubic centimetre than bone marrow, indicating that
with sufficient sampling volumes, stem cell expansion may
not be required in certain stem cell treatment modalities [30].
In clinical practice, the potential of fillers or scaffolds cur-
rently on the market has been limited in supporting an engi-
neered tissue replacement therapy for defect repair or tissue
restoration. Identifying the ideal filler in combination with
tissue’s own stem cells could hence provide an optimized
microenvironment in which to create an engineered tissue
that can be used as a semipermanent filler material. In this
aspect, recent studies have shown that adipose-derived stem
cells can be almost the ideal source of cells for rejuvenating
soft tissue therapies [31]. Owing to their multipotentiality
and propensity, results have indicated that it is relatively sim-
ple to achieve a high level of adipose differentiation from
adipose-derived stem cells in vitro, and numerous approaches
have recently been developed to use them in vivo [32, 33]. It
was further argued that not only these cells can replace the
parts of lost soft tissue, adipose-derived stem cells seem to
have an important capacity in inducing angiogenesis or
1241
neovasculogenesis, which is also one of the main require-
ments or the challenges of the contemporary soft tissue
repair/augmentation [34, 35].
Nowadays, results of the numerous animal studies that
have been mostly performed on mice, rats, rabbits, dogs
and horses have shown that it can be even possible to aug-
ment the clinical outcome by combining filler or scaffold
(either autologous or synthetic) with enriched stem cells.
Many scaffolds associated with adipose stem cells have so
far been examined for their use in soft-tissue treatment,
including resorbable materials such as poly(lactide-co-gly-
colide acid), hyaluronic acid sponge and esters, collagen
sponges [2, 36].
In order to follow a more natural as well as more physio-
logical approach, several authors used autologous fat as a
matrix and supplemented the transplant with autologous
adipose-derived stem cells, namely cell-assisted lipotransfer.
Long-term follow-up (>1 year) results in general have indi-
cated significantly improved outcome compared to conven-
tional lipofilling in soft-tissue volume restoration cases [19,
37, 38]. These studies also indicated the importance of not
only the adipogenic differentiation potential of ADRCs but
also their angiogenesis-inducing ability that can be crucial to
create a more stable and predictable volume retention. In the
light of these findings, it has also been speculated that com-
bining the regenerative cells with growth factor/inducer-rich
supplement and autologous fat tissue scaffold can create an
optimal tissue repair system. In other words, cells stimulated
with certain chemical compounds can be combined or trans-
ferred into a matrix or scaffold to construct an implantable
product in order to create engineered soft tissue filler that is
constructed from autologous sources. In this way, tissue via-
bility can be increased and as a result the consistency of graft
survival may be improved. This unique approach is called as
Stem Cell Enriched Tissue (SET) injection [39, 40]. In these
injections, isolated autologous ADRCs are mixed with
patient’s own platelet-rich plasma (PRP) and then redistrib-
uted in the scaffold with the help of a syringe. It is thought
that resulting engineered scaffold can promote angiogenesis
during the critical time of tissue engraftment, thus improving
the survival rate of tissue and reducing postoperative volume
attrition.
1.4 Isolation and Delivery Methods
Although there are many publications related to isolation and
culture of ADRCs in the literature, all protocols utilize more
or less similar isolation and culture protocols which consist
of mainly (i) enzymatic digestion of the aspirated fat, (ii)
hemolytic removal of red blood cells and (iii) isolation of
stromal vascular fraction (SVF) cells by centrifugation.
Depending on the experimental or clinical setting, SVF cells
1242
Table 1 Comparison of different approaches in contemporary lipotransfer applications
Direct fat injection Selective fat injection
Graft uptake ↑(highly variable) ↑↑ (variable)
Ease level No special handling No special handling
Cost No additional cost No additional cost
Duration of the procedure ~60 min ~60 min
Purification level None None
~ADSC density (per mm3) 1× 1×
are either culture-expanded for several passages or directly
used without cell expansion [1].
When recent clinical studies are analyzed, it can also be
seen that so far there exist four different modes of lipotrans-
fer practice (without or with cellular components) world-
wide: (a) direct fat injection, (b) selective fat injection, (c)
injection of fat tissue and SVF cells together in a procedure
named as cell-assisted lipotransfer (CAL), (d) enrichment of
SVF cells by magnetic separation and combining these cells
with fat tissue (SET).
Table 1 shows the differences in certain technical and pri-
mary outcome parameters among different lipotransfer pro-
cedures. Results show that the main drawback of direct or
selective fat injection procedures is the unpredictable vol-
ume retention ratios, hence the possibility of a need for
repeated procedures. Although this drawback is relatively
minimized in CAL procedures, possibly due to the insuffi-
ciency in blood supply, variabilities in volume retention can
be higher with increased volume of the lipotransfer. In SET
injections, on the other hand, volume retention can be very
satisfactory; hence, in nearly all cases reported, no additional
session of lipofilling was required. However, the latter
approaches necessitate the establishment of a cell processing
facility in or nearby the operation room.
Use of stem cell–based technologies in clinical setting
necessitates the production or preparation of cells under
good manufacturing practices. Numerous regulatory authori-
ties including The Food and Drug Administration (in USA)
and European Medicines Agency (in Europe) have devel-
oped guidelines for clinical-grade cell production. These
guidelines have continuously been revised and updated as
new scientific evidences and results are published. According
to the current research and clinical practice, utilization of
cells that are obtained with minimal manipulation (without
ex vivo culture expansion) can be integrated more easily in
clinical trials [41].
In order to meet the need for minimally manipulated
adipose-derived stem cell production, Cytori Therapeutics (San
Diego, CA, USA) and Tissue Genesis (Honolulu, HI, USA)
have designed a closed device (Cellution) which can allow the
C. Calabrese et al.
Cell-assisted lipotransfer Stem cell-enriched tissue
(CAL) (SET) injection
↑↑↑ (% 40–90 or more) ↑↑↑↑ (% 70–90 or more)
Requires a cell separation Requires a cell separation
unit and purification unit and purification
equipments equipments
Additional cost for cell Additional cost for cell
separation and enrichment separation and enrichment
~90 min ~120 min
None Enriched
2× >50×
production of clinical-grade cells within the operation room in
an acceptable time frame that is suitable for immediate clinical
application [40, 42]. The device is now available in the
European and Asian markets and under regulatory review in
the USA. Apart from many of its proposed advantages, for
cases in which a very small amount of tissue replacement is
required, manual cell preparation has been shown to give supe-
rior results [39]. Therefore, depending on the initial volume of
the fat tissue to be processed, in the authors’ clinical setting,
two different procedures are utilized for SET: manual cell
enrichment and automated cell enrichment.
1.5 Cell Enrichment Procedures
1.5.1 Manual Cell Enrichment
Magnetic cell separation has recently become a standard
method for cell separation in a variety of different research
and clinical applications. The most commonly used mag-
netic cell separation system in the contemporary literature is
MACS®. This system is mainly characterized by the appli-
cation of nano-sized particles with superparamagnetic char-
acteristics. Particles are 20–150 nm in size and made of an
iron oxide core and a dextran coating. In the presence of a
strong magnetic field, iron cores strongly magnetize, but
when the magnetic field is removed, the particles do not
retain any residual magnetism. Also, the dextran coating on
the outer surface of the beads permits chemical conjugation
of other biomolecules such as antibodies, fluorochromes, oli-
gonucleotides, etc. Depending on the desired cell products,
by application of magnetically labeled antibodies in the het-
erogeneous cell mixture, one can purify a desired cellular
content. Utilization of antibodies against the cells to be iso-
lated is termed as “positive selection”, whereas by using
antibodies against undesired cell populations, one can enrich
the desired cell population by simply eliminating the
antibody-bound cells from the environment, which is called
“negative selection or depletion”.
It is very important to note that these particles are biode-
gradable and do not alter cell function. Therefore cell labeled
Aesthetic Regenerative Surgery 1243

with MACS® microbeads have so far been used for many

functional in vitro experiments, in vivo animal studies and
therapeutic transplantations in humans [43–45].
Magnetic cell separation technology was initially applied
to enrich and purify hematopoietic stem cells from bone
marrow or peripheral blood during transplantation proce-
dures. Today, the majority of the cases in which magnetic
cell separation is used are still allogeneic hematopoietic stem
cell transplantations, autologous hematopoietic stem cell
transplantations in autoimmune diseases and stem cell trials
for tissue regeneration such as cardiac tissue. There exists
small but growing interest in applications of this technology
in aesthetic or plastic and reconstructive surgery. For exam-
ple, Ishimura and colleagues have used magnetic cell sorting
technology to isolate CD105+ cells in order to compare the
current chondrocyte differentiation strategies and they found
out that magnetic separation is a very efficient and reproduc-
ible protocol for ADRC enrichment [46]. Our group has also Fig. 1 Post incubation period. Lipoaspirate is allowed to settle
applied this technology in 29 cases and the results indicated
the improved and comparable outcome in terms of volume
retention as well as patient satisfaction [39].
Based on the above facts, in our clinical setting, manual
cell isolation and enrichment have been performed by utiliz-
ing MACS® cell separation system in the “Laminar Flow
Cell Isolation Unit” in the operation room. The main benefit
of using such a unit is that the lipo-aspirated fat is transferred
to the operator immediately after harvesting; therefore, no
time is wasted between sampling and processing phase. Also,
since the sample is all the time kept in the operation theatre,
the isolation and processing phases are all done under the
same sterile conditions. While the separation process takes
place, the major fat aspiration, transfer and tissue shaping is
done immediately in the OR using traditional lipostructuring
techniques, and the patient is sent to the ward. Also, we have
utilized “negative depletion” strategy during cell sorting.
Since our understanding on stem cell characterization is being
expanded exponentially, isolating stem cells based solely on
Fig. 2 QuadroMacs system (Miltenyi Biotech)
the known surface markers would potentially exclude the
unknown but beneficial stem or progenitor cell population in
the sample. Therefore, our primary strategy was based on the filtered through 100 mm and 40 mm filters in order to remove
exclusion of all non-stem cells from the isolated SVF such as tissue debris and extracellular materials. After the filtration,
lymphocytes, monocytes, granulocytes, etc. the content is mixed with equal amounts of stop solution
If less than 50 cc of SET is planned to be transplanted, which contains DMEM (Invitrogen), L-glutamine
manual cell enrichment is the preferred cell processing (Invitrogen), antibiotics (Invitrogen) and 10 % patient own
approach. For each 20 cc of transferred fat, 20 mg of lipoaspi- serum to inactivate the material. Following centrifugation
rate is taken as a cellular source and upon reaching the labo- step at 1,300 rpm for 10 min, the pellet is re-suspended with
ratory the sample is poured into a 25 or 75 cm2 tissue culture red blood cell lysis solution. The pellet is centrifuged again
flask and mixed with enzyme cocktail for tissue digestion. and prepared for magnetic separation. For cell separation,
Enzyme cocktail consists of type II collagenase (Invitrogen) QuadroMACS system (Miltenyi Biotech) is used (Fig. 2).
and trypsin (Invitrogen). The mixture is then placed in a Pelleted cells are re-suspended with rinsing solution
water bath and incubated at 37 °C with continuous and rigor- (Miltenyi Biotech) which contains 0.2 % HSA. In order to
ous shaking. After incubation period, the mixture is left to separate mature blood cells from cells with stem cell poten-
settle (Fig. 1) and the stromal vascular fraction (SVF) is tial, lineage cell depletion kit (Miltenyi Biotech) with LS
1244
separation columns (Miltenyi Biotech) is used according to
manufacturer’s instructions.
This process takes around 120 min and the readily sepa-
rated autologous ADSCs in 2–10 ml of patient’s own platelet
rich plasma (PRP) solution are injected generally directly
with a 30 G needle into the fat-grafted area, using the fat
graft as a living transfer scaffold.
1.5.2 Automated Cell Enrichment
In cases of fat transfers for more than 100 cc, an automated
magnetic unit, Celution System TM (Cytori Therapeutics;
San Diego, CA, USA) which uses a similar isolation process
without a magnetic unit, in a closed system with a proprie-
tary good manufacturing practice (GMP) standard, clinical-
grade enzyme is used according to the manufacturer’s
instructions. This device gives the operator the option of
utilizing up to 350 cc of SET and the procedure takes
90–120 min, depending on the volume of adipose tissue.
It has to be noted that for both procedures (either manual
or automated enrichment) the quality and quantity of stem
cells are influenced by the tissue harvest and cell isolation
techniques, whether cryopreservation for long-term storage
have applied, and most importantly, by donor-dependent
characteristics such as age and gender.
Proposed Mechanism of Action in SET Applications
Adipose tissue, unlike many others, continuously undergoes
expansion and regression. Therefore, in theory, a need for a
tightly modulated capillary networking is necessary. Recent
in vitro as well as in vivo animal studies have also indicated
that adipogenesis and angiogenesis are reciprocally regu-
lated. That is, ASRCs can exert their positive effects on vas-
cular tube formation, and endothelial cells can in return
stimulate preadipocyte proliferation and differentiation.
Therefore, it becomes obvious that in order to obtain satis-
factory clinical results, delivery of endothelial progenitor
cells can be as important as ADRCs. For ADRC isolation,
unlike hematopoietic stem cell transplantations, positive
selection of certain ADRC cell population by magnetic cell
separation would in fact result in decrease in vascularization
potential unless these endothelial progenitors are not
selected. For this reason, the use of negative depletion strat-
egy and excluding fully differentiated blood-borne cells such
as B and T cells from the cellular mixture would create an
enriched but heterogeneous stem cell population which may
potentially have increased capability of repairing a defect. In
the SET system, an additional potential benefit is to use
autologous adipose tissue as a natural scaffold. In this way,
also without a need of a potential donor search, aspirated or
excised tissue pieces can be easily used for therapeutic rea-
sons, unless there is a genetic defect.
C. Calabrese et al.
2 Clinical Applications: Face and Breast
2.1 Face: Small Volume Injections
for the Face
2.1.1 Consultation and Patient Selection
As time passes, different parts of the face age as a conse-
quence of different reasons. This fact forces the doctors to
use and combine various methods to deal with these prob-
lems. In the upper third of the face, the main reason of
aging is the excessive usage of the mimetic muscles. To
deal with these dynamic wrinkles, Botulinum toxin injec-
tions are accepted as the state-of-the-art treatment modality
[47]. In the lower third of the face, the main problem is
related to gravitational sagging, which in turn is dealt with
various skin lifting techniques [48]. Volume depletion is
the most important factor causing the aging of the middle
third of the face. Accordingly, either volume redistribution
or volume replacement is the basic approach to mid-facial
aging. Autologous fat injection is an accepted and widely
described technique for volumetric treatment [49].
However, the limitations of fat transplantation are well
known in some cases, particularly the long-term unpredict-
ability of volume maintenance. By combining traditional
fat grafting with ADRCs, tissue viability and, therefore, the
consistency of graft survival may be improved. The sug-
gested advantages are reduced downtime due to higher
graft uptake, single session treatments and a higher regen-
erative capacity due to cellular promotion of angiogenesis
and regenerative processes.
Ideal patients who are candidates for enriched tissue
transplantations are patients who have basically a midfacial
volume loss (Fig. 3), and particularly those who have possi-
ble graft uptake restrictions due to fibrosis, congenital or
acquired diseases with a lack of genuine blood supply
(Fig. 4). During the consultation, the patient should be
informed about the surgical procedure, postoperative swell-
ing and oedema and also about possible limitations and risks
related to traditional fat injection.
2.1.2 Risks and Complications
Based on today’s literature, complications associated with
enriched fat grafting are similar to traditional lipofilling.
These include infection, bleeding, fat embolism and graft
volume loss. From the technical perspective, since the proce-
dure requires no further culturing of isolated or enriched
cells, the procedures are free from xenogenic cell culture
materials such as fetal calf serum and hence can be called as
“minimal cell and tissue manipulation”. Still, the patient has
to be informed about the usual side effects like bruising and
swelling.
Aesthetic Regenerative Surgery 1245

a b

Fig. 3 A 44-year-old female patient. Cosmetic facial-enriched tissue injection. Single session, 24 cc. (a) Preoperative. (b) Postoperative 1 year
1246 C. Calabrese et al.

a b

Fig. 4 A 41-year-old female patient with dermatofibromatosis. Single session, 46 cc of enriched tissue injection and skin resection. (a) Preoperative.
(b) Postoperative 1 year

2.1.3 Technique: A Short Overview of preparing stem and regenerative cells from a variety of
The safety, efficacy and final outcome of any given case is tissues reported and there is no industry standard for prep-
dependent on the technique used. There are several methods aration of a cell-enhanced graft [41]. The operations are
Aesthetic Regenerative Surgery
generally performed under local anaesthesia with or with-
out sedation and the grafts are harvested primarily from
the lateral thighs, lower back and abdomen.
For cases in which less than 100 cc of SET was required, the
graft is usually processed manually. In these instances, half of the
lipoaspirate was transferred to the Laminar Flow Cell Isolation
Corner in the operating room within 10 min of harvest in order to
minimize cell death. In cases of greater than 100 cc of SET, half
of the lipoaspirate was introduced into an automated system
within 10 min of harvest for cell isolation to begin.
While cell isolation takes place, the majority of the fat
transfer and tissue shaping is done using traditional lipo-
structuring techniques. For the injection, 1 cc syringes for
the face and 5 cc syringes for the body are used in order to
accurately control the volume of graft injected. To reduce the
time of the procedure, two syringes are used simultaneously.
While the one syringe is used for an injection, the other is
filled with the graft material in preparation for the next injec-
tion. After the micro-fat grafting procedure is finished, the
patient is sent to the ward to await ADRC injection, which in
turn reduced the operation theatre occupation by as much as
120 min. Later in the ward, the readily prepared autologous
ADRC/PRP solution is injected with a 30 G needle directly
into the fat grafted area, using the fat graft as a living transfer
scaffold. Effort is made to evenly distribute the ADRC/PRP
solution evenly throughout the grafted area [39].
2.1.4 Donor Site Selection, Preparation,
Infusion
There is no firm evidence to define the best donor site for fat
grafts. Various studies have shown differences in cell viabil-
ity or graft quality from different anatomical sites [11], but
Rohrich et al. found that common harvest areas (abdomen,
flank, thigh, medial knee) produce statistically equivalent
numbers of viable cells [50]. The abdominal region has been
reported as the most common harvest location due the fact
that the patients are typically supine for graft delivery [13].
After photographic documentation, donor site is marked
preoperatively. Lipo-harvesting can be performed under
local anaesthesia, with IV sedation or general anaesthesia.
Standard sterile technique is during the harvest and conven-
tional prophylactic antibiotics are sufficient. The donor site
is infused according to the preferences of the doctor; usually
a tumescent solution is used.
2.1.5 Patient Positioning and Fat Harvesting
For facial injections, the amount of transplant tissue is mini-
mal, so the patient is best laid on the back. This position
enables the surgeon to symmetrically harvest fat from any
location. If larger amounts of transplant are needed, harvest-
ing can be started with the patient in the facedown position.
In this way, larger amounts of fat can be taken from the back
of the body, without any positional disturbance. For the
1247
aspiration and fat transfer, a 3 mm cannula and traditional
Coleman injection cannulas are used, respectively.
2.1.6 Delivery of the Graft
According to current data, grafts placed within 2 mm of an
arterial blood supply have minimal necrosis and should be
expected to survive. In order to increase the graft uptake, the
graft surface area is maximized, using the Coleman method of
delivering small parcels of fat in different tunnels. For the face,
a blunt 17-Gauge cannula with a 1-ml syringe is preferable.
In order to increase the graft uptake, it is necessary to use
the whole depth of the recipient area. This is valid also for
facial injections where the placement shall start directly on
the top of the periosteum, continuing layer by layer more
superficial. Superficial subcutaneous level can be used for
injection except of the periorbital area where the skin thick-
ness is not enough to mask the grafted droplets. Preseptal
area is to be spared of grafting.
2.1.7 Combining the Graft
with the Enriched Cells
The enrichment of the graft by the isolated stem cells can be
done in two ways. Noting that regenerative cell isolation usu-
ally takes about 2 hours, the major fat grafting and lipo-
modelling can be performed in the OR at the initial stage.
The patient can be sent to the ward after the procedure in
order to empty the operating theatre. After receiving the iso-
lated cells, these can be injected in the patient’s own platelet-
rich plasma into the fat-grafted area using 1-ml syringes and
dental needles, thus using the transplanted fat as transfer
scaffold [51]. Another way is to wait until the cell isolation
is done, the cells can be mixed with the graft material in vitro,
and graft injection can be performed later on in a similar
manner as in the automated cell enrichment procedures.
2.1.8 Postoperative Care
Usually, sutures to close the incisions are not necessary.
Generally, dry dressings with elastic tapes are applied to the
donor area, the recipient sites are left open except steri-strips
for the entrance punctures. Oedema and bruising are com-
mon and are expected to resolve in about 2 weeks. Application
of ice packs onto the recipient area is a traditional and useful
postoperative procedure.
2.2 Breast: Large Volume Injection
in the Breast (with the Contribution
of the Cell Society)
Fat grafting to the breast has main goals in obtaining volume
enlargement preserving shape and symmetry. Immediate
association of adipose engineered tissue can also obtain a
correct implant coverage in severe malformations. When the
1248
a b
Fig. 5 Engineered tissue treatment strategies in breast aesthetic sur-
gery. (a) Breast ipoplasia in symmetric breast candidate for augmenta-
tion with fat engineered tissues. (b) Malformation with severe
indications are to achieve a shape, a mastopexy can also be
integrated to the adipose tissue transplantation (Fig. 5).
2.2.1 Consultation and Patient Selection
Patients must understand the achievable outcomes of breast
grafting procedures. Fat transplantation may not entirely replace
prosthetic breast placement, depending on the patient’s avail-
able donor volume of fat and recipient site anatomy. Also
important is discussing a patient’s family and/or personal cancer
history. Women who desire large and firm breast may not be
appropriate candidates for autologous fat transfer as fat grafts
result in a more natural looking appearance. Similarly, it cannot
be overemphasized that fat grafts to the breast are not a viable
option for women lacking significant sources of donor fat for
liposuction, because the need for fat is much higher when com-
pared to other indications for fat grafting procedures.
2.2.2 Technique: A Short Overview
The adipose engineered tissue is prepared by combining adi-
pose-derived regenerative cells with traditional lipostructure
techniques for cosmetic breast enhancement. This is an intra-
operative one-step procedure obtained by an automated sys-
tem (Celution System by Cytori Therapeutics) which isolates
the ADRC in a closed, optimized and automated process.
Harvesting the Fat
Main principles for lipoharvesting are to determine the donor
site based on patient preference, positioning for graft place-
ment and surgeon experience, to infiltrate tumescent fluid in a
volume ratio of 1:1, volume of expected graft harvest to vol-
ume of tumescent fluid injected. The automated system and the
related procedures will process the harvested fat part for cell
isolation and part for scaffold creation. Since the discovery of
adipose-derived regenerative cells in fat tissue, many scientists
and surgeons have begun to use these cells to supplement or
enrich fat grafts. ADRC are in stromal vascular fraction derived
from enzymatic digestion of adipose tissue which includes
C. Calabrese et al.
c
asymmetry: right candidate for integrated treatment implant/fat engi-
neered tissue. (c) Ipoplastic tuberous breast candidate for fat grafting to
breast associated with periareolar mastopexy
adipose-derived stem cells, preadipocytes and vessel-forming
cells. It is thought that ADRC contributes to graft survival by
directly or indirectly aiding in vascularization of the graft.
The Engineered Tissue
Following the principles of tissue engineering, the cellular frac-
tion derived by the harvested fat must be combined with a scaf-
fold. Since in breast aesthetic surgery enhancing volume is the
main goal, the lipoaspirate will represent the ideal volume/scaf-
fold solution. Interactions between cells, scaffold and host will
reduce fat reabsorption promoting the graft intake. The lipoaspi-
rate processing techniques will also impact on the fate of the
transplanted tissue. Lipi Vage (Genesis Biosystem) is a fat har-
vest, wash and transfer system that functions without the need for
a centrifuge. Tissue-Trans (Shippert Medical) is another autolo-
gous fat grafting device that offers a sterile, non-traumatic method
for harvesting adipocytes. Pure graft is based on a lipodialysis
technology and consists in a bilaminar membrane filtration/flow
system. It allows for dial-in graft hydration since the water con-
tent of the graft is dependent on the final drain time (Fig. 6).
Delivering the Engineered Tissue
Graft survival is dependent on diffusion until a new blood sup-
ply can be established. Multilayer injection of graft microdro-
plets will maximize the surface area of the graft that is exposed
to the surrounding tissue and encourage diffusion of oxygen
and nutrients. Regarding the incision placements for breast,
they are commonly made around the areola, in the inframam-
mary crease and/or in the outer edges of the upper poles. To
optimize fat graft survival, close proximity to a blood supply
is imperative. Although injection cannula diameter has not
been shown to affect cell viability, Coleman recommends
using a blunt 17-Gauge cannula with a 1 ml syringe for fat
injection. To improve the delivery techniques to maximize the
graft surface area, various devices have been developed.
Cellbrush by Cytori Therapeutics is a microdroplet injection
device specifically designed for autologous fat grafting and
Aesthetic Regenerative Surgery 1249

a b

c d

Fig. 6 (a) Preoperative front, lateral view and 3D MRI image in adipose engineered tissue breast augmentation. (b) Four months follow-up after adipose
engineered tissue with ADRSC and dialyzed fat-like scaffold (310 cc in the right side, 290 in the left). Shape and volume in 3D MRI reconstruction

allows a tactile feedback during tissue dispersion in addition to
minimizing syringe pressure build-up. For the breast, graft
should be injected in the intramuscular or subcutaneous space,
but not in the mammary gland or retromammary space.
2.2.3 Complications and Risks
Currently, the greatest drawback of fat grafting is the unpredict-
ability in longevity and stability of grafted tissues. While many
will report extraordinary outcomes, most studies evaluating
long-term graft survival will quote 10–80 % survival. With
such a wide range of results, optimization and standardization
of the procedure is critical. The development of focal fat necro-
sis following fat grafting is strongly an operator-dependent
phenomenon. Infection is rare while lipid cysts occur at a rela-
tively low rate subsequent (approximately 15 %) when proper
technique is used. Calcifications are a normal occurrence
resulting from any breast intervention, including fat grafting
procedures. Benign calcifications caused by fat necrosis should
be easily recognizable and discernible from those indicative for
breast cancer, and therefore should not affect the detection of
breast cancer or cause unnecessary biopsies.
Patients should undergo a breast imaging control prior to
grafting to confirm that no breast cancer is present.
Physicians should inform patients that should they develop
breast cancer, grafting should not hinder any conventional
cancer treatment options. Autologous fat grafting subse-
quent to mastectomy reconstruction is not expected to cause
an increase in patient oncologic risk when compared to sim-
ilar patient population who had not undergone post-mastec-
tomy reconstruction with fat graft [52].
3 The Future in Clinical Applications
3.1 Fillers and Skin
The improvement of skin quality after fat injection to the
face, breast or any previously damaged area is a long
observed data [13]. But any advantage of skin quality
improvement after regenerative cell enrichment of the fat
compared to traditional fat grafting has not been observed in
long series of facial rejuvenative injections [53]. This is pos-
sibly due to the fact that the regenerative cells are injected to
the deep tissue but not particularly into the dermis itself,
where a visible improvement is expected. A mix of regenera-
tive cells with a dermal filler, presumably hyaluronic acid
might pave our way to the birth of personalized fillers into
the skin, for a local regenerative effect.
1250 C. Calabrese et al.

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 Index

A Thorek’s mesogastric excision, 318, 319

Abdominal region vertical excision, 318, 319
hips, 328, 329 Ablative laser technology
subumbilical area, 328, 329 biopsy skin samples, 1108
surgical anatomy CO2 fractional mode of resurfacing, 1105
adipose tissue, 326–327 erythema, 1106
arterial vascularization, 327–328 occlusive dressing, 1106
innervation, 328 phototype and wrinkles, 1105
lymphatic network, 328 post-operative skin signs, 1106, 1107
muscles, 327 pulse density programme, 1105
skin, 325, 326 Skin 125× HE/EO, 1108, 1109
umbilical area, 328, 329 Skin 250× HE/EO, 1109, 1110
Abdominoplasty, 79 skin phototype, 1105
abdominal region (see Abdominal region) skin pigmentary disorders, 1110
Beck’s technique, 315, 316 tissue healing time, 1106, 1107
Callia’s transverse-inguinal-pubic incision, 317, 318 tissue stimulation, 1110
Castaňares’ mixed technique, 318, 319 topical anaesthesia, 1106
check list, 344–345 upper lip resurfacing, 1106, 1108
complications, 341–342 wrinkles and phototype, 1106
Demars and Marx’s technique, 315, 316 Accessory nostril. See Supernumerary nostrils
dermolipectomy, 323–324 Acellular dermal matrix (ADM), 254, 310
French-bikini like incision, 317, 318 Acquired breast asymmetry
Frist’s technique, 315, 317 ADM, 254
iconographic acquisition, 331 breast ptosis, 254, 256
imperfections, 341, 342 capsular contracture, 254, 255
informed consent, 332–333 nipple/areola complexes, 254, 256
Kelly’s technique, 315, 316 preoperative and postoperative views, 254, 255
liposuction, 343 secondary, 247
patient preparation, 333 Actinic keratosis, 1096–1097
patient selection and evaluation, 330–331 Acute complications
patient’s positioning, 332 fat necrosis, 297
preoperative drawing, 333–334 hematoma, 295–296
principles, 325 infection, 296
skin incision, 325–236 NAC necrosis, 297, 298
surgical technique seroma, 296
abdominal dissection, 334, 335 skin necrosis, 296–297
complete dissection, 334, 335 wound dehiscence, 296–297
craniocaudal traction, 335 Acute post-operative pain management
cyanoacrylate skin adhesive, application of, 340–341 factors, 84
dead space closure, 339 gabapentin, 86
deep fascia anchoring, 340 ketamine, 86
disinfection and preparation, 334 local anaesthetics, 87
drain positioning, 339–340 neuro-axial block, 85
excess dermo-adipose portion marking and removal, 338 NSAIDs, 85–86
flap dissection, 334 opioids, 86
immediate postoperative appearance, 340, 341 paracetamol, 86
isolation of umbilical scar, 335, 336 tramadol, 86–87
navel anchoring, 338–339 VAS, 85
oblique muscles plication, 336, 337 verbal scales, 85
rectus muscles plication, 335–336 Adipocytes and regenerative cells (ADRCs), 1035, 1036
umbilical measurement, 337 ADM. See Acellular dermal matrix (ADM)
umbilical scar dissection, 334 ADRCs. See Adipocytes and regenerative cells (ADRCs)

© Springer Berlin Heidelberg 2016 1253

N. Scuderi, B.A. Toth (eds.), International Textbook of Aesthetic Surgery, DOI 10.1007/978-3-662-46599-8
1254 Index

Aesthetic breast surgery skin

acute complications excess skin, 922
fat necrosis, 297 infraauricular and submandibular lipectomy, 926–927
hematoma, 295–296 muscle laxity, 922
infection, 296 patient classification I, 922, 923
NAC necrosis, 297, 298 patient classification II, 922–923
seroma, 296 patient classification III, 923–924
skin necrosis, 296–297 SMAS, 923
wound dehiscence, 296–297 superficial adipose tissue, 924–926
augmentation mammoplasty, 118–120 typology, 921
breast mound asymmetry, 307, 308 SMG
breast reduction and mastopexy, 117–118 alloplastic materials, 952
chest wall asymmetry, 307, 308 anatomical structures, 952
fat grafting, 121 anterior approach, 952
hypertrophic scarring, 310 antero-superior and posterior faces, 952
implant malposition camouflaging technique, 950
double-bubble deformity, 299–300 cleavage plane, 952
inferior, 299, 300 commencing resection, 953, 955
lateral, 301 DTC, 952
medial/synmastia, 301, 302 gland repositioning, 950
superior, 301–303 intra/extraoral approach, 950
implant placement, 310 lateral approach, 952
implant-related sequelae lipofilling, 952
autologous fat injections, 310 local myoadipose flaps, 952
capsular contracture, 308–309 mandible and cervico-mandibular angle, 953
deflation/rupture, 310 mandibular branches, 950
form-stable silicone gel breast implants, 310 mandibular hypoplasia, 952
rippling/wrinkling, 309–310 particularly complex case, 953, 957
mastopexy and augmentation, 120 platysma identification, 953, 954
NAC asymmetry, 307, 308 preoperative phase, 950
parenchymal replacement, 120 reduction, 953
ptosis, 303, 304, 306–307 short neck, 953, 956
rates, 298 subplatysmal fat, 952
risks and complications, 311 tangential plane, 952
size change superficial adipose tissue (see Platysma muscle)
factors, 302 Aimed Subcutaneous Segmentary Glandular Resection (ASSGR), 271
in-office deflation, of saline implant, 303, 305 Alei’s technique, 499–500
severe asymmetry, 303, 305 The American legal system
smaller size, 303, 304 aesthetic plastic surgery liability, 93
soft tissue coverage, 120 defense attorney’s prospective
timing of, 298 advertising and warranty, 111
wound necrosis, 117 authoritative literature, 110
Aesthetic plastic surgery liability, 93 causation, 110
Aesthetic regenerative surgery charting, 111
adipose-derived stem/regenerative cells, tissue repair, defendant physician’s testimony, 111
1234–1235 discovery phase, 109
autologous fat, tissue repair, 1234 expert witness, 110–111
breast (see Breast) hypothetical patient, 111
cell enrichment procedures, 1236–1238 informed consent, 110
face (see Face) post-deposition, 112
isolation and delivery methods, 1235–1236 standard of care, 110
tissue engineering, 1233–1234 trial, 113
Ageing necks healthcare pact, 104
deep adipose tissue HIPAA, 89–90
closed liposuction, 948 lawsuit, 107–109
fat faces, 947 legal principles
fat neck, 947 The Antithesis of the Concrete, 95–96
intradigastric fat, 947 The Burden of Proof, 97–98
quantity and localisation, 947 business and insurance business, 101–102
subplatysmal lipectomy (see Subplatysmal The Concept of a Legal Duty, 96
lipectomy) crises, 103
superficial fat, 947 Depositions and Related Stuff, 99–100
deep musculo-fascial structures, 953 English law, 95
neck aesthetics, 921 expert and standard of care, 97
perihyoid fascia, 953 interrogatories, 99
Index 1255

language’s inherent ambiguity, 95–96 preoperative plan, 937

medical malpractice trial, 98, 100–101 running suture, first layer of, 941, 942
physician economics, 102–103 subhyoid plication, 939–941
protective social device, 95 suprahyoid plication, 939, 940
reasonableness and negligence, 97 tension, 940–941
Requests For Admission, 99 Antiaging
transcription error, 99 caloric restriction, 1229–1230
managed care risks, 93–95 cell cycle control, 1213
medical malpractice claim, 106–107 cosmeceuticals
office staff, 104 antiacne agents, 1202
patients, 104 antioxidants (see Antioxidants)
The Plaintiff Attorney Viewpoint, 95 anti-redness agents, 1202
plastic surgery office risks, 91–93 botanicals (see Botanicals)
“Pogo,” 105–106 cleansers, 1186
prescription drug, 104 enzymes, 1200–1201
and “Rule of Law,” 89 growth factors, 1201
TORT/medical malpractice, 90–91 hormones, 1201
trial lawyers, 103–104 hydroxyacids, 1191–1193
Anaesthesiological techniques irritant and allergic dermatitis, 1202–1203
deep sedation/analgesia, 65 masks and astringents, 1186–1187
general anaesthesia, 65–66 metals, 1198–1200
MAC, 66 moisturization, 1185–1186
minimal sedation, 65 nonphenolic agents, 1197–1198
moderate sedation/analgesia, 65 peptides, 1202
monitoring, 67 phenolic agents (see Phenolic agents)
PONV, 67 photoaging, 1187
Ancillary lower eyelid reconstructive techniques, 788, 791 proteins, 1202
Ancillary treatments, trunk and abdomen retinoids, 1187–1188
cellulite, 515 skin barrier, 1183–1184
mechanical massage, 517 skin type, 1184
mesotherapy and lipolysis, 518–519 dehydroepiandrosterone, 1231
optical devices, 517 effective antiaging strategy, 1217
radiofrequency, 516 facial rejuvenation, 841
randomized controlled trial, 515 human growth hormone, 1231
ultrasound, 517–518 klotho, 1231–1232
Anesthesia Lycium barbarum, 1230
MACS lift, 903 melatonin, 1233–1234
midface rejuvenation, 891 mental functional capacity, 1214
reoperative surgery, 968 metformin, 1232
roundblock SMAS treatment, 877 oncogene/anti-oncogene homeostatic balance, 1213
Anesthetic approaches (ASA) organs and apparatus deregulation, 1214
abdominoplasty, 79 physical inability, 1214
anaphylaxis, 80 rapamycin, 1232
breast augmentation/reduction, 79 resveratrol, 1233
general anesthesia, 77 sirtuin activators, 1232–1233
liposuction, 79 telomere shortening, 1213
local anesthetic toxicity, 80 testosterone, 1230
low flow anesthesia, 77–78 Antioxidants, 1230
MAC, 76–77 alpha-lipoic acid, 1190
MH, 80 dimethylaminoethanol, 1190
office-based procedures, 80 genistein, 1190
OR fires, 80 hydroxyacids, 1191
PONV, 79–80 isoprostanes formation inhibition, 1219
rhytidectomy, 78–79 micronutrients, 1218
“Superwet” technique, 79 in skin care products, 1191
Angiomas, 1125 spin traps, 1190–1191
Anterior sutures ubiquinone, 1190
corsetplasty, 939–940, 943, 944 vitamin B3, 1189
high decussation and flaccid platysma, 938 vitamin B5, 1189
horizontal segment, 938 vitamin C, 1189, 1218
lateral platysma, 940 vitamin E, 1189–1190, 1218–1219
lateral traction, 937 AntiPTOSic (APTOS), 973
midline suture, 937–939 The Antithesis of the Concrete, 95–96
muscular diastasis, 937 Anxiolysis (minimal sedation ), 65
plication, 938, 939 Apert syndrome, 669
1256 Index

Argon laser, 1127 surgical drains and dressings, 140

Asian upper blepharoplasty surgical techniques, 137–138
anatomical consideration, 753–754 traumatic rupture, 141
complications, 757–758 ultrasound assisted percutaneous drainage, 140
surgical techniques wound dehiscence, 140
buried non-absorbable suture, 755
incisional fixation technique, 755
nonincisional suture technique, 755 B
preoperative and postoperative results, 756–757 Babcock’s technique, 323, 324
skin marking, 755 Bag centrifugation (khouri) method, 154
subtle variations, 755 Baldness
Aufricht, Gustave, 588 androgenic alopecia
Augmentation mammoplasty in men, 525–526
antisepsis, 118 in women, 527
fibrous capsule contracture, 120 doctor-patient approach
implant placement, 120 medical history, 534–535
prosthesis, 120 physical examination, 535
sterilization, 119 free ohmori temporo-parieto-occipital flap, 529
Augmentation mastoplasty galea, role of, 537
anatomy, 128, 131 hair bulbs, 535
autologous fat hair direction, 535, 536
breast lipostructure, 127 hairline design, 535, 536
“Celution” device, 128 incisions, orientation of, 535
Coleman’s technique, 127 infiltration, 535
lipofilling, 127 innervation, 533–534
patients, tuberous breasts, 128–130 Juri temporo-parieto-occipital flap, 528
Puregraft system, 128 Passot flap, 527
Baker scoring system, 140 physiology, 525
body weight and thoracic conformation, 132 preauricular Dardour flap, 529
breast implants, 125–126 retroauricular Dardour flap, 529
calcifications, 143 structures, 537
capsular retraction, 142 superior pedicle flap, 528
capsule and implant selection, 141 surgical anatomy, scalp, 530
capsulectomy, 141 vascularization
classification arteries, 530
autologous tissue, 124 occipital artery, 530, 532
implants, 124–125 posterior auricular artery, 532
injectables, 123–124 supratrochlear and supraorbital arteries, 532
complications and treatment, 140 veins, 532
digital imaging, 132 Baso cell carcinoma, nose, 18, 20
extrusion, 143 Beauty, cultures
generic complications, 140 Aphrodite, 3, 4
hematoma, 140 Beatriz d’Estrées portrait, 16
hypomastia, 123 Discobolo, 3, 4
implant Egyptian sculpture, 5
dislocation, 141 facial proportions and skin, 14
left implant dislocation, 141, 142 feminine beauty, 6, 8
pocket preparation, 139 feminine, wide hips, 3
positioning, 132–133, 139–140 human proportions, 7, 11
shape, round/anatomic, 135–137 human skin, canvas, 14, 15
inadequate tissue coverage, 132 ideal facial proportions, 7, 12
informed consent, 142–143 ideal female body, 5–6
with injectables, 128 La Maja Desnuda, 6, 10
interference, diagnostic imaging, 143 with lean athletic, 5, 6
patient’s anatomy, 131 lean feminine body, 5, 7
periprosthetic capsular retraction, 140 Olympia, Manet, 6, 10
pinch test, 131–132 Seated Woman, 6, 11
postoperative medication, 128 skeletal framework, 12, 13
preoperative measurements and implant selection, 134–135 skeletal references, 7, 12
primary mastoplasty, 143 skin perfection, 14, 15
rippling, 143 smiling faces, 12–14
secondary mastoplasty, 143 Venus d’Urbino, 6, 9
sensitivity alterations, 143 and virtue, 3
skin marking, 138 Beck’s technique, 315, 316
stretching and atrophy, breast tissues, 132 Belt and suspenders technique, 812, 814
surgical access, 139 Bilateral gynecomastia, 292
Index 1257

Binder syndrome, 669 muscular areas, 1074–1076

Blair procedure, 678–679 perioral rejuvenation, 1079
Blefarocalasis, 741 platysma muscle, 1079–1080
Blepharoplasty structure, 1073
Asian upper (see Asian upper blepharoplasty) targeted areas, 1076–1077
brow lifting, 1140 temporal brow lift, 1077–1078
complications treatment, 1075–1076
early (1st week) (see Early postoperative period (1st week)) Bourguet’s method, 850
intermediate (1st-6th week) (see Intermediate postoperative Brachial dermolipectomy, 318
period (1st-6th week)) Brachioplasty
late (7th week and beyond) (see Late postoperative period anatomy and aging process, 435
(7th week and beyond)) axilla tissue, 441
endoprosthesis, 1139 complications, avoidance of, 437–438
Endotine™ prosthesis, 1138, 1140 flap appearance, 440
lateral canthal surgery (see Lateral Canthal Surgery) fusiform excision, 318, 320
lower eyelid (see Lower eyelid blepharoplasty) laxity and soft-tissue redundancy, 438–439
minimally invasive approach (see Minimally liposuction cannula, 442
invasive approach) operative description, 436–437
postsurgical discomfort and tissue repair, 1140 patient selection, 436
upper blepharoplasty and eyebrow elevation, 1140 patient’s left arm, 439
upper eyelid patient’s right arm, 438, 439
complications, 751 peri and postoperative care, 437
intraoperative adjustment of markings, 749, 750 Pitanguy elliptic axillary excision, 318, 320
male vs. female, 747 preoperative planning, 435–436
medial fat, 748, 749 refining approaches, 436
normal anatomy, 748, 749 suction-assisted lipectomy, 441
patient markings, 748, 749 tailor-tack technique, 441
pre and postoperative results, 750 with “T” closure, 318, 320
preoperative evaluation and consultation, 748 upper arm laxity/redundant tissue, 438
without browlifting, 750–751 W-plasty, 319
Botanicals Brauer-Foerster procedure, 679, 680
allantoin, 1195 Breast
aloe vera, 1195 large volume injection
capsaicin, 1195 complications and risks, 1249
chamomile, 1196 consultation and patient selection, 1244
curcumin, 1194 graft survival, 1248
Echinacea, 1195 lipoharvesting, 1248
garlic, 1195 tissue engineering, 1248–1249
Ginkgo biloba, 1194 lipostructure, 127
ginseng, 1195 ptosis classification
glycyrrhizin, 1195 false/pseudoptosis, 177
grape seed oil, 1194–1195 glandular, 177
kinetin, 1194 minor, 177
lavender, 1196 moderate, 177
podophyllotoxin, 1195 severe, 177
pomegranate, 1196 Breast asymmetry
pycnogenol, 1194 acquired
saw palmetto, 1196 ADM, 254
silymarin, 1194 breast ptosis, 254, 256
soothing agents, 1195 capsular contracture, 254, 255
soy, 1193–1194 nipple/areola complexes, 254, 256
St. John’s wort, 1196 preoperative and postoperative views, 254, 255
tea leaves, 1194 secondary, 247
tea tree oil, 1194 congenital
Witch Hazel, 1195 age and mental maturity, 248
Botulinum toxin (BOTOX®) breast feeding, 248
complications, 1076 circumareolar mastopexy, 248, 249
crow’s feet and natural eyebrow lifting, 1077, 1078 constricted/tuberous breast, 250–251
facial muscular anatomy, 1074, 1075 gel implant, 250, 251
facial nerve injury, 1078–1079 inverted-T incision, 248, 250
formulations, 1074 Poland’s syndrome, 247
frontalis transverse forehead lines, 1078 primary augmentation, 248
glabellar frown lines, 1077 secondary, 247
history, 1073 size/shape variances, 247
immunologic considerations, 1080 unfurled breast tissue, 251–253
mechanism of action, 1073 vertical mastopexy technique, 248, 250, 251
1258 Index

Breast augmentation progressive telomere shortening, 1214

Baker classification, 188 stem cells, self-renewal and multi-lineage differentiation, 1215
capsular tissue, 189 telomere shortening, 1214
definition, 185 Cephalometry, 701
implant dislocations, 189 Cheiloplastics
Mycobacteria cultures, 189 anaesthesia, 1052
physiological changes, 188 anatomy, 1047–1048
and reduction, 79 arteries, 1050
reoperation rate classification, 1051–1052
calcifiednodular capsule, 186–187 contour, 1059–1062
erythematous spot, 187–188 cutaneous strata, 1049
implant stability, 185–186 fillers, 1053
implant style/volume, 185 graft and implant
medico-legal aspect, 186–187 autologous and alloplastic materials, 1053
Mentor core study, 185 Coleman method, 1055
tissue changes, 189–190 derma, 1054
tissue releaseain, 188–189 dermic graft pre and post-surgery, 1054, 1057
Breast hypertrophy incisions, 1054, 1055
gigantomastia (see Gigantomastia) lipofilling, evalution of, 1055, 1058
inverted-T scar reduction mammoplasty lip stretched bilaterally, 1054, 1056
advantages, 217, 218 post-surgery, 1055, 1058
classification, 194–195 pre-surgery, 1055, 1058
complications, 218 PTFEe, 1054, 1056
de-epithelialization, 215–217 substitute synthetic material, 1054
glandular and adipose tissue, 217 temporal fascia and orbicular muscle, 1053
objectives, 215 transition line and contour, 1054, 1055
pectoralis major muscle, 217, 218 trochanteric region, 1054, 1057
physical symptoms, 193 informed consent, 1065, 1069
preoperative drawing, 215, 216 long lip
report data, 215 cutaneous exeresis, 1062, 1063
suture phases, 217, 218 lip length, 1063, 1064
tailor principle, 215 lip lift, 1063
vertical bipedicle McKissock type, 215 local oedema, 1063
vertical pedicle technique, 215 lower lip, 1060
The Burden of Proof, 97–98 margins without tension, 1062, 1063
Byzantine surgery, 722 senile long lip, 1063, 1064
standard superior incision line, 1062, 1063
surgical procedure plan, 1062, 1063
C upper lip, 1060
Callia’s transverse-inguinal-pubic incision, 317, 318 lymphatic vessels, 1051
Caloric restriction (CR), 1218, 1229–1230 melanin, 1049
Canthopexy motor innervation, 1051
aggressive resurfacing procedure, 1136, 1137 mucous strata, 1050
lower eyelid skin tension, 1135 muscular strata, 1049, 1050
scleral exposure, 1135 senile lip acquired, 1047, 1048
Canthoplasty techniques, 788, 790 sensitive innervation, 1051
Canthotomy subcutaneous strata, 1049
laser resurfacing, 1136, 1138 submucous strata, 1049, 1050
transconjunctival blepharoplasty, 1136, 1138 surgical technique, 1052
upper eyelid skin laxity and dermatochalasi, 1138, 1139 thin, long lip congenital, 1047, 1048
Carboxytherapy, 451–452 unique epithelium cover, 1048
CO2, 1160–1161 veins, 1050
facial rejuvenation treatment, 1163 volume reduction, 1065–1069
therapeutic purposes, 1161 `V-Y’ eversion
therapeutic uses, 1162 asymmetrical upper lip, 1056, 1059
transport and disposal, 1161–1162 incision line, 1056, 1059, 1060
Castaňares’ mixed technique, 318, 319 infiltration process, 1059
Cellular senescence lip length, 1059, 1064
aging phenotype, 1214 lower lips, 1055
DNA damage, 1214 pre and post-surgery, 1059, 1061
epidermal lineage selection, 1215 reference lines, 1056, 1059, 1060
genotoxic stress, 1214 senile long lip, 1059, 1064
gerontology, 1215 surgical procedure plane, 1056, 1059
immune-inflammatory stimuli, 1214 three contiguous triangles, 1057
limited replicative potential, 1214 upper lips, 1055, 1056, 1059
oncogenic/tumor suppressor signals, 1214 vermilion, 1059
Index 1259

Chemical peelings Celsus, Aulus Cornelius, 722

acne scars, 1096
actinic keratosis, 1096–1097
chronoaging, 1096
complications, 1098
dermatological procedure, 1095
freckles, 1096
Glogau’s classification, 1097
medium
combination peeling, 1102–1103
phenol, 1103–1104
pyruvic acid, 1102
trichloroacetic acid, 1102
melasma, 1096
patient’s pre-treatment evaluation, 1097
photoaging, 1096
skin priming, 1097
skin rejuvenation, 1095
solar lentigo, 1097
spots, 1096
superficial
glycolic acid, 1095, 1098–1099
Jessner’s solution, 1101
mandelic acid, 1099–1100
post-peel exfoliation, 1101
resorcinol, 1101
retinoic acid, 1100
salicylic acid, 1100–1101
YP, 1101
very superficial, 1095, 1096
Chemosis, 803–804
Chongchet technique, 829–830, 832
Chromophores, 1123
Circumareolar mastopexy, 248, 249
Coleman’s technique, 127
The Concept of a Legal Duty, 96
Congenital breast asymmetry
age and mental maturity, 248
breast feeding and subsequent breast changes, 248
circumareolar mastopexy, 248, 249
constricted/tuberous breast, 250–251
gel implant, 250, 251
inverted-T incision, 248, 250
Poland’s syndrome, 247
primary augmentation, 248
secondary, 247
sizeshape variances, 247
unfurled breast tissue, 251–253
vertical mastopexy technique, 248, 250, 251
Congenital tubular nose. See Proboscis lateralis
Conjunctival edema. See Chemosis
Constricted ear, 821
Converse and Wood-Smith technique, 828–831
Corsetplasty, 939–940, 943, 944
Cortisone, 1116
Cosmetic breast augmentation
fat grafting (see Fat grafting)
size and shape, aesthetics
mega volume fat grafting, 156
“Rigottomy” technique, 156
table surface irregularities, 156
“Three-Dimensional Needle Band Release,” 156
Cosmetic eyelid surgery, history of
in Ancient Egypt, 721
blepharochalasis correction, 724
Byzantine surgery, 722
ectropion correction, 724–725
eyelid operation, 724, 725
in India, 721
in Mesopotamia, 721
middle age, 722–723
renaissance, 723
in Rome, 721
upper and lower eyelid incisions
crow’s-feet corrections, 728
Eitner’s method, 728, 730
excess skin removal, 726
pre and postoperative result, 726, 727
with scalpel, 724
skin excision, 726, 727
Cosmetic patient anesthesia
ASA (see Anesthetic approaches (ASA))
careful patient selection and preparation, 75–76
patient safety, 75
Cosmetic surgery anaesthesia techniques
anaesthesiological techniques, 65–67
inhaled anaesthesia, 68–69
local anaesthetics, 67–68
modern intravenous anaesthesia, 69–72
pain stimulation, 64–65
preoperative medical visit, 63–64
Cottle technique, 691–692
Cranial remodelling in adults, 18, 23, 24
Craniofacial correction completion, aesthetic operations, 23, 25–26
Craniofacial syndromes, 669
Cronin technique, 677, 679, 680
D
Deep facial fascia (DFF), 889
Dehydroepiandrosterone (DHEA), 1231
Demars and Marx’s technique, 315, 316
Depressor orbicularis oculis lateralis, 962–963
Dermal orbicular pennant lateral canthoplasty (DOPLC), 794–796
Dermal pigmentation
chalazion formation, 817
dry eye syndrome, 817
lashes, 817
palpebral fissure asymmetries, 818
Dermaroller® micro needling, 1170
Dermoabrasion
breast feeding, 1179
coagulopathy, 1179
dermatological chronic conditions, 1179
diabetes mellitus, 1179
facial rejuvenation, 1177
Golgau classification, 1177
herpes active lesions, 1179
HIV infection, 1179
immunosuppression, 1179
isotretinoin, 1179
modern rejuvenation techniques, 1176
pathological healing, 1179
preoperative evaluation, 1177
rejuvenation technique, 1177
skin surface irregularities/mask scars, 1176
treatment, 1178–1179
Dermolipectomy, 323–324
Devine and Horton technique, 498–499
DFF. See Deep facial fascia (DFF)
Diagnostic photography and photometric evaluation, 54
1260 Index

Diced cartilage-fascia (DCF) graft, 644, 646 lateral retinaculum, 739

Dingman technique, 679 lower tarsal muscle, 739
Distinct abdominal obesity, 330–331 LPTL, 739
Distraction test, 774 medial canthal tendon, 740
Double eyelid procedure. See Asian upper blepharoplasty MHSL, 739
Dry eye syndrome, 817 post-aponeurotic space, 739
Duckett’s technique, 495 pretarsal/preseptal part, 737
Dyspareunia, 512–514 SMAS, 736
subcutaneous layer, 736
superior and inferior tarsus, 738
E superior transverse ligament/Whitnall’s ligament, 738–739
Early postoperative period (1st week) surgical topographic anatomy, 740–741
central retinal artery occlusion, 802 tarsal strap, 740
chemosis, 803–804
corneal abrasion, 802
dry eye, 802 F
eyelid hematoma, 802 Face
eyelid sloughing, 803 lifting
globe perforation, 801–802 cervical tumour, 18, 19
orbital hemorrhage cervico-rhytidectomy, 847
etiology, 800 commercial setting, 848
examination, 800 cosmetic procedures, 847
incidence, 800 definition, 848
intraoperative control of hemostasis, 800 elliptical templates, 848
management, 801 extensive skin, 848
postoperative prevention, 800–801 fascia superficialis, 851
preoperative evaluation, 800 frontal-naso-labial rhytidectomy, 847
pseudomonas preseptal cellulitis, 803 Joseph face-lifting incisions, 851, 852
visual loss, 799–800 Lexer face-lifting incisions, 851, 852
Ebbehoj and Metz technique, 499 maxillo-facial surgery, 850
Eitner’s method, 728, 730 oblique-vector loop, 848
Empty pouch effect, 926 operations, 845
Encore Ultrapulse® Active FX™ device, 1105, 1111 pre and postoperative images, 846, 849
Endogenous hormone stimulation, 241 reoperative surgery (see Reoperative surgery)
Erythrosis, 1126 SMAS, 852
Expanded Poli-Tetra-Fluoro-Etilene (PTFEe), 1054 suspension technique (see Suspension technique)
External ultrasound-assisted lipoplasty (EUAL), 350 suspension threads and vertical vector, 851
Extracorporeal septoplasty, 692–694 transconjunctival approach, 850
Eyeball small volume injections
conjunctival space, 734, 735 consultation and patient selection, 1238
fascial sheath of the bulb/Tenon’s capsule, 734 donor site selection, preparation and infusion, 1247
intermuscular membrane, 735 enrichment, graft, 1247
levator muscle, 735, 736 graft delivery, 1247
oblique muscles, 735 patient positioning and fat harvesting, 1247
ocular muscles, 734 postoperative care, 1247
orbital/arrest tendons, 736 risks and complications, 1244
rectus inferior, 735–736 technique, 1246–1247
rectus muscles, 735 Facial aging
superior rectus, 735, 736 anatomical changes, 855, 856
Eyebrow surgery expression lines and wrinkles, 857
blepharoplasty, 1138–1140 factors, 906
canthopexy, 1135–1136 ptosis and tethering
canthotomy, 1136, 1138 composite unit, 857
Eyelids labiomandibular fold and jowl, 863, 864
lax lower eyelid lateral brow ptosis, dynamics of, 858
blepharoplasty, 1138–1140 lid-cheek region and advanced age, 859–860
canthopexy, 1135–1136 ligamentous boundaries, 858, 861
canthotomy, 1136, 1138 lower lid bags, 860
orbitopalpebral region malar fat pad, 862
adipose compartments, 738 malar mounds, 861
anatomy, 736, 737 mandibular branch injury, 864
anterior and posterior lamellae, 736 maxillary projection, loss of, 859
capsulopalpebral fascia, 739 medial orbital fat bulges, 860
central/palpebral part, 736–737 midcheek, 858, 859
ITL, 738 nasojugal and palpebromalar grooves, 861
lateral canthal tendon, 739 nasolabial segment, 861
Index 1261

premasseter space, 863–864 monopolar therapy, 1157–1158

preseptal space, 859, 861 Ohm’s law, 1155
prezygomatic space, 861, 862 risk assessment, 1159–1160
ROOF, 858 skin cooling, 1156–1157
SMAS, 862 therapy, 1156
subcutaneous plane, 864 transport and disposal of co2, 1161–1162
temporal hooding, 858, 859 Facial skin pigmentation disorder
skin tissue layers, 855–856 fractional resurfacing treatments, 1142
Facial asymmetry, moderate orbital dystopia, 18, 22 melasma patches, 1143
Facial lipofilling photothermolysis, 1144–1145
adipose tissue, 1033 pulsed fractional ablative CO2 laser, 1143
ADRC, 1035 thermal gradient, tissue, 1144
advantages, 1045 treatment program, 1143
autologous fat graft, 1031, 1033 Fat grafting, 121
Carraway technique, 1034, 1035 adipocyte transplantation, 145
celution system, 1035–1036 clinical categories, 146
chin, 1039 fat harvesting, 146–147
Coleman’s technique, 1033–1034 fat injecting and shape-modifying techniques, 147–148
complication, 1041 fat processing, 147
disadvantages, 1045 harvesting
face anatomy, 1032–1033 bag centrifugation method, 154
face components, 1031 large syringe method, 154, 155
facial atrophy, 1040, 1042 liposuction, 153
facial embryology, 1031–1032 machine method, 154
fat tissue compartments, 1031 syringe collection method, 154
frontal area, 1036 mapping technique, 155
infiltration, 1034–1035 mega volume grafting, 146
informed consent form, 1044 negative pressure, breast, 149
liposuction, 1034 one-stage breast augmentation, 157–158
lips, 1037, 1039 patient evaluation and selection, 149–150
local anaesthesia with sedation, 1040–1041, 1043 percent yields, 147
lower eyelids lipofilling, 1037, 1038 physiology, 145
mandibular margin, 1039, 1040 postoperative management, 156–157
marionette furrows, 1037, 1038 preoperative preparation, recipient site, 150, 152–153
nasogenian furrow lipofilling, 1037, 1038 reverse liposuction technique, 155, 156
naso-labial and marionette furrow, 1037 shape modification, “Rigottomy,” 148
nose, 1040, 1041 stem cell-enriched, 145
osseous and cartilaginous systems, 1031 two-stage breast augmentation, 158, 159
palpebral/periorbitary zone, 1036, 1037 types, 145
regenerative stem cells and growth factors, 1035 Fat injecting and shape-modifying techniques
zygomatic-malar area, 1036 hole sizes, 147
Facial profile imaging, 53 mapping technique, 147, 148
Facial rejuvenation reverse liposuction technique, 147, 148
carboxytherapy Fat necrosis, 297
therapeutic purposes, 1161 Filler
therapeutic uses, 1162 characteristics of, 1084
transport and disposal, 1161–1162 injection technique
treatment for, 1163 hyplopasia and asymmetry, 1090–1091
chemical peels, 841–842 implantation depth, 1088
with CO2 laser ablative resurfacing (see Ablative laser technology) infiltration site, 1088
cosmetics, 841, 843 linear threading, 1089
dermabrasion, 842 polylactic acid, 1090
fillers serial puncture, 1089
fat injection, 845 surface implant, 1088–1089
liquid silicone, 844–845 permanent synthetic fillers
minimally invasive cosmetic procedures, 845 hydroxyapatite, 1087
paraffin wax, 842–844 polyacrylamide, 1087
rubber and gutta-percha, 844 polymethylacrylate, 1087
Fountain of Youth, 841, 842 silicone, 1086–1087
massotherapy, 1163–1165 temporary biological filler
radiofrequency collagen, 1085
bipolar therapy, 1158–1159 dextran, 1086
CO2, 1160–1161 hyaluronic acid, 1085–1086
collagen heating, 1155 injectable agarose gel, 1086
exclusion criteria, 1159 polylactic acid, 1086
monopolar and bipolar, 1156, 1157 polyvinyl alcohol, 1086
1262 Index

Fioravanti, Leonardo, 587 skin markings, 242, 243

Fishtail excision, 836 skin scars and quantity, 244
Fitzpatrick classification, 1114, 1124 superior pedicle, 242, 243
Follicular unit extraction (FUE) technique treatment of, 242
contraindications, 551 ulnar neuropathy, 239
Inaba’s technique, 549 vascular anatomy, 241
indications, 551 wedge resection, 242, 243
micromotor, 550 Glabella frown lines, 857
surgical instruments, 549 Glandular flap correction type III, 262
tumescence, 550 Glandular flap correction type IV, 262
Forehead and brow rejuvenation Glogau’s classification, 1097
aesthetic brow, 868–869 Gluteoplasty
aging process body mass index, 473–474
brow skin and periorbita, 870 complication rates, 472
motor innervation, 868 fat transfer, 474
musculature, 867–868 anatomic intramuscular, 478
sensation, 868 intramuscular implants, 479
browlifts, 867 implant selection, 477, 480
closure, 871 implant size selection
complication, 873 implant exposure, 479
coronal incision, 867, 871 wound dehiscence, 479–480
endoscopy, 871–873 incision evolution, 482, 484
indications, 870 lateral view, 480, 482
minimally invasive procedures, 867, 871 muscle height-to-width ratio, 480, 482
operative technique, 871 muscle tension, 473
peri and postoperative care, 873 patient’s expectation, 472
plastic surgery, 867 postoperative care, 489–490
preoperative planning, 869–870 preoperative preparation
restore youthful appearance, 870–871 anesthesia, 484–486
rhytidectomy technique, 871 drains, 489
Forked technique, 676, 677 fat grafting, 484
Framing and reference grids implant placement/closure, 489
breast imaging, 45° projection, 53, 54 incision design/markings, 486
digital camera grid, 52 muscle dissection, 487–488
ears, 53 patient preparation, 484
eyes, 53 sizers/implant size, 488–489
facial profile imaging, 53 skin flap dissection, 486–487
Francoforte’s plane, 52 tissue expansion, 488
head, 52–53 subfascial plane, 481
lower limbs, 53, 54 elastomer implants, 480
torso, 53, 54 size selection and implant texture, 479
upper limbs, 53 surgical indications, 476
Fraser syndrome, 669 V-shaped gluteal appearance, 474, 476
French-bikini like incision, 317, 318 Gynecomastia
Frist’s technique, 315, 317 adipose, 288
Furnas technique, 826–829 classification and clinical aspects, 287–288
definition, 285
diagnosis test, 288
external appearance, 285
G glandular, 288
Gabapentin, 86 idiopathic gynecomastia, 285, 287
General anesthesia (GA), 65–66, 77 mixed, 288
medical aid, 65 neurofibromatosis, 285, 286
muscle relaxants, 66 pain and tension, 288
pharmacologically induced loss of consciousness, 65 signs and symptoms, 288
Gigantomastia, 235 single-stage vs. two-stage surgery, 291, 292
clinical features, 239 surgery
clinical manifestations, 239 external incisions, 291, 293
immediate postoperative view, 242, 243 general anesthesia, 289
lateral pillars, 242, 243 glandular resection, 290, 291, 293
moderate and severe hypertrophy, 239, 240 incision line, 289
morphologic differences, 239 intraoperative, 289
pathogenesis, 241–242 liposuction, 289, 291, 293
preoperative view, 242, 243 reduction mammaplasty and mastopexy, 289
sensory innervation, 241 skin retraction, 291
Index 1263

H Hemostasis, 836, 837

Hair transplantation, 545–547 Hindu reconstruction techniques, 585
advantages, 545 HIPAA. See Health Insurance Portability and Accountability Act
carbon dioxide laser, 543 (HIPAA)
complications, 546 Horizontal lid shortening (HLS) technique, 783
disadvantages, 545–546 horizontal pentagonal wedge resection, 791, 793
dressing, 545 negative canthal tilt, 789, 791
eyebrow reconstruction, 547–548 snap and distraction test, 789, 791
frustule, 543 soft tissue, 789, 791
FUE technique Hormonal therapy, 1222–1223
contraindications, 551 Human growth hormone (GH), 1231
Inaba’s technique, 549 Hump osteotomy
indications, 551 Aufricht retractor, 607
micromotor, 550 “Bayonet” hump, 607
surgical instruments, 549 concave dorsum, 606
tumescence, 550 convex dorsum, 606
graft insertion phase, 544 Joseph periosteum retractor, 607
graft preparation, 542–543 median fracture, 608
harvesting techniques, 541–542 rasp level, 608
historical background, 539 scalpel, 608
informed consent, 551–552 Hydrocelectomy, 506
mono, bi, and tri bulbar grafts, 544 Hyperprolactinemia, 241
postoperative course, 545 Hypertrichoses, 1127, 1129
postoperative medical therapy, 545
preoperative guidelines, 540
pubic hair restoration, 548 I
surgical instruments, 544 Indinavir, 241
surgical operation Inferior pedicle reduction mammoplasty
donor site preparation, 540 advantage and disadvantage, 207
hairline design, 540 contraindications, 208
local anesthesia, 541 dressing, 211
preliminary phases, 540–541 indications, 207
tumescence, 541 preoperative drawing, 208–211
Hand rejuvenation surgical procedure, 208, 210–211
anatomy and physiology Inferior retinacular lateral canthopexy (IRLCx)
adipose tissue, 446 advantage, 790
color of skin, 446 preoperative and postoperative, 791, 793
genetic/biological and environmental factors, 446 procedure, 791, 792
hand anatomy, 447 Inhaled anaesthesia, 68–69
palmar skin, 446 Injection technique
photoaging, 447 genieno nose furrow and thin vermilion, 1090–1092
subcutaneous tissue, 446 hyplopasia and asymmetry, 1090–1091
superficial fascia, 446 implantation depth, 1088
upper limb, 446 infiltration site, 1088
UV radiations, 447 linear threading, 1089
wrinkles and dark flecks, 447 polylactic acid, 1090
biorevitalization, 449 pronounced genieno nose, 1090, 1092, 1093
carboxytherapy, 451–452 serial puncture, 1089
complications, 452 surface implant, 1088–1089
dyscromias, 450 Intense pulsed light (IPL) systems
embryology, 445 complications, 1129
lipofilling, 449 epilation
peelings, 450 anamnesis, 1128
photorejuvenation techniques, 448 argon laser, 1127
phototoxic and aging factors, 448 biopsies, 1128
polylactic acid injection, 451 excessive hair, 1127
radiofrequency effect, 449 genetic predisposition, 1127
superficial burns and edema, 448 hair growth center, 1127
Health Insurance Portability and Accountability Act hypertrichosis, 1128
(HIPAA), 89–90 facial rejuvenation
Hemangiomas, 1125 Fitzpatrick classification, 1124
Hematoma, 295–296 patient’s characteristics, 1125
Hemiperiareolar/circumareolar access photo-damaged skin, 1124
with breast implant insertion, 179–180 filters, 1123
with dermoparenchymal rectangular flap, 180, 181 indication, 1123
1264 Index

Intense pulsed light (IPL) systems (cont.) cutaneous histology

operative device, 1123 Fitzpatrick classification, 1114
pulse length, 1123 Rubin classification, 1114
treatment of, 1123–1124 superficial epidermal layers, 1114
TRT, 1123 erbium laser, 1114–1116, 1119
vascular anomalies and pathologies excessive skin repositioning, 1113
etiology, 1126 MST/CO2, 1116, 1118, 1119
hemoglobin absorption, 1126 non-ablative laser, 1114
patient’s hypersensitivity, 1126–1127 selective photothermolysis
zygomatic region, 1126 dermal heating, 1113
Intermediate postoperative period (1st-6th Week) epidermolysis, 1113
corneal exposure, 806 variable-pulse erbium laser, 1117–1119
lagophthalmos, 805 Lasers and intense light systems
lower eyelid malposition breast reduction
cicatricial ectropion, 805, 806 areola-nipple necrosis, 1147, 1148
infected malar implant, 805, 806 and breast ptosis, deepithelization stage, 1145
management, 805–806 cyst formation, 1146
moderate inferior scleral show, 805, 806 Peixoto technique, 1147
predisposing factors, 805 chemical peels, 1133
postoperative ptosis, 804 chronological aging, 1133
preoperative ptosis, 804–805 collagen deposition, 1133
strabismus and extraocular muscle disorder, 806–808 corticosteroid therapy, 1140
Intermuscular transverse ligament (ITL), 738 Cushing’s syndrome, 1140
Interplatysmal, 947 eyelid and eyebrow surgery (see Eyebrow surgery; Eyelids)
Inverted-T scar reduction mammoplasty IPL treatment, skin disorder, 1140–1142
inferior pedicle flaps laser cartilage reshaping, surgical otoplasty, 1145
advantage and disadvantage, 207 lip functional restoration and rejuvenation, 1149–1150
contraindications, 208 mechanical dermabrasion systems, 1133
dressing, 211 medical treatments, 1151
indications, 207 nose reshaping, 1148–1149
preoperative technique, 208–211 pigment disorders, 1133
surgical technique, 208, 210–211 pixel-based algorithm, 1141
superior (see Superior pedicle flaps) plastic aesthetic procedures, 1151–1152
scar revision, Co2, 1133–1135
scar tissue, trichloroacetic acid peeling, 1150, 1151
K surgical aesthetics, 1133
Kelami’s technique, 499 Late postoperative period (7th week and beyond)
Kelly’s technique, 315, 316 dermal pigmentation
Ketamine, 86 chalazion formation, 817
Killian procedure, 691–692 dry eye syndrome, 817
King Ferdinand I of Sicily, 586 lashes, 817
Klotho, 1231–1232 palpebral fissure asymmetries, 818
eyelid crease abnormalities, 815
Fasanella-Servat procedure, 808–810
L hypertrophic scarring, 816
Labia majora and minora lagophthalmos, 809–810
4.0 catgut suture, 511 lower eyelid malposition
clitoral hood reduction, 511 anterior and posterior lamella, 811, 813
dyspareunia, 512–514 cicatricial lower eyelid retraction, 810, 811
embryology and anatomy, 509 eyelid stretching, 810, 811
hymenoplasty, 511 inferior cantholysis, 811, 812
indications, 509 lateral canthal angle, 813–814
labia minora hypertrophy, 509 lateral canthal incision, 811, 812
W-shaped resection, 510 lateral tarsal strip completion, 811, 813
Lamivudine, 241 middle lamellar deficiency, 810
Large Syringe (del vecchio) method, 154 orbital septal release, 811, 813
Laser resurfacing periosteal slot, 811, 813
clinical studies Polydek suture, 812, 814
antibiotic use, 1116 posterior lamellar deficiency, 810
erbium lasers, 1115 strip attachment, 812, 814
geometrical design scanners, 1115 tarsal suspension, 810, 812
healing processes, 1115 malar festoons, 815, 816
operative behavior, 1115 over-resection, 814–815
reepithelialization process, 1115 ptosis, 808
CO2 laser, 1113–1114, 1117 suture tracks and granulomas, 815–816
complications of, 1118 under-resection, 815
Index 1265

Lateral canthal surgery patient selection, 377

ancillary lower eyelid reconstructive techniques, 788, 791 postoperative period, 380–381
bone/periosteal fixation, 783 scarpa fascia, 379
canthoplasty techniques, 788, 790 statistics of, 384
de-epithelialized dermal pennant, 783, 784 surgical marking, 377
distraction test, 788 suture of layers, 380
DOPLC, 794–796 surgical techniques, 376
eyelids and periocular structures, 785 Lipofilling, 852, 917–919
HLS techniques, 783 Lipoplasty, 352–354
horizontal pentagonal wedge resection, 791, 793 blood loss, 348
negative canthal tilt, 789, 791 blunt instrumentation, 348
snap and distraction test, 789, 791 clinical application, 351
soft tissue, 789, 791 invasive and noninvasive technologies, 351
horizontal lid laxity, 788 LLLT, 351
IRLCx PAL, 350–351
advantage, 790 stem cell research, 352
preoperative and postoperative, 791, 793 superwet technique, 349
procedure, 791, 792 ultrasound technology, 349–350
lateral canthal suspensions, 783 in U.S, 348–349
laterally based periosteal flap, 784–785 uterine curette, 347
medial-based periosteal flap, 784–785 windshield wiper type approach, 347
MFS, 796, 797 Liposuction, 79, 227
palpebral apertures, 787 Lipsett’s technique, 616
positive and negative canthal tilt, 788 Lower eyelid blepharoplasty
positive and negative vector, 788, 789 aging periorbita, external features of, 761, 763
procedure, 788–789 anatomy
snap test, 788 bony insertions, 762, 764
tarsal strip procedure, 783, 784 fat compartments, 762, 765
tear breakup time, 787 infraorbital fat pad prominence/palpebral bags, 766
TS lower lid fat and resultant changes, 762, 765
beady eye appearance, 794 malar festoons, 765
tarsal strip procedure, 793 muscle, 762, 763
variations, 784, 793 nerve supply, in periorbital region, 764, 765
upper and lower canthal fixation, 783 rejuvenative procedures, 766
upper eyelid lateral canthal structure, 784–785 tarsoligamentous support structures, 762, 764
variations, 788 tear trough deformity, 766
vertical distraction test, 788 complications, 770–772
VSG, 794, 795, 797 surgical techniques
Zone I, 785 bovie, 766
Zone II, 785–787 canthopexy, 768, 769
Zone III, 786 canthoplasty integrates cantholysis, 769
Zone IV, 786–787 dissection, 766, 767
Zone V, 787 fat grasping, 766–767
Lateral sutures infraorbital and zygomatic facial nerves, 766, 767
completed sutures, 945, 946 lateral canthal fixation, 768
excess tissue, 945 lateral orbital rim, 769, 770
lateral anchorage, 941 lateral skin triangle, deepithelialization of, 769, 770
Lorè’s fascia, 945 ligamentous attachments, 768
mastoid fascia, 941 lower lid laxity, 768, 769
muscular flap, 941 lower lid skin muscle flap, 766, 767
platysma undermining, 945 nasal fat pad, 768
postero-oblique traction, 941, 943 refinements, 766
SMAS-platysma, anchorage of, 945 skin muscle flap, 769–770
vertical vectors traction, 941, 943, 946 subciliary incision, 766, 767
Lipoabdominoplasty Lower eyelid malposition
anatomy, 375–376 intermediate postoperative period (1st–6th Week)
Saldanha’s technique cicatricial ectropion, 805, 806
complications, 384–385 infected malar implant, 805, 806
conservative approach, 382 management, 805–806
dressing, 380 moderate inferior scleral show, 805, 806
epigastric and subcostal liposuction, 378 predisposing factors, 805
fundamentals, 377 late postoperative period (7th week and beyond)
infiltration, 378 anterior and posterior lamella, 811, 813
infraumbilical fuse and rectus muscle plication, 380 cicatricial lower eyelid retraction, 810, 811
lower abdomen, 378–379 eyelid stretching, 810, 811
omphaloplasty, 380 inferior cantholysis, 811, 812
1266 Index

Lower eyelid malposition (cont.) disclaimer, 433

lateral canthal angle, 813–814 financial responsibilities, 432–433
lateral canthal incision, 811, 812 health insurance, 432
lateral tarsal strip completion, 811, 813 risk factor, 430–432
middle lamellar deficiency, 810 suction-assisted lipectomy surgery, 430
orbital septal release, 811, 813 for surgery, 433
periosteal slot, 811, 813 mid-torso laxity, 417
Polydek suture, 812, 814 minimal access cranial suspension, 414
posterior lamellar deficiency, 810 psychological conditions and nutritional deficiencies, 409
strip attachment, 812, 814 RYGBP procedure, 409
tarsal suspension, 810, 812 skin laxity, 410
Lower level laser therapy (LLLT), 351 surgical techniques
Low flow anesthesia, 77–78 abdominoplasty, 421
Lycium barbarum, 1230 bariatric surgery, 421
body contouring surgery, 421
circumferential surgery, 417
M electrocautery, 419
Machine Method (Del Vecchio), 154 excision site liposuction (ESL), 419
Macromastia, 239 Fleur-de-Lis excision, 417
Male genital aesthetic surgery HIVAMAT, 420
anatomy, 493–495 oral diuretics, 419
complications, 506 upper body lift, 420–421
embryology, 493 VASER®, 419
hydrocelectomy, 506 wound closure, 417
informed consent, 506–507 total body lift surgery
penile lengthening buttock augmentation, 422–423
dysmorphophobia, 500 lower body lift, 422
pubic lipectomy and liposuction, 502 thighplasty, 423, 425
pubocavernous space-maintainer positioning technique, 502 upper body lift, 424–426
suspensory ligament incision technique, 501–503 upper chest laxity, 414
V-Y flaps, 501 vertical upper body laxity, 417
penis enlargement Massotherapy
dermal matrix technique, 503–504 applications, facial rejuvenation, 1165
lipofilling, 504 face and neck, manual massage, 1163–1164
scaffolds technique, 503 mechanical massage, 1164–1165
silicone and hyaluronic acid filling, 504–505 Mastopexy
testicular prosthesis implantation, 505–506 and augmentation, 120
penis straightening and breast reduction, 117–118
Alei’s technique, 499–500 with implants
Devine and Horton technique, 498–499 breast ptosis, 177
Ebbehoj and Metz technique, 499 capsular contracture, 181
Kelami’s technique, 499 circumareolar pattern, 178, 179
Montague’s technique, 499 combined mastopexy augmentation, 181
Nesbit’s technique and variations, 498 fat necrosis, 182
Udall’s technique, 499 hemiperiareolar pattern, 178
Yachia’s technique, 499 implant dislocation, 181–182
surgical techniques rippling, 182
Duckett’s technique, 495, 496 skin-gland mastopexy, 182
meatoplasty, in distal hypospadia, 495 skin/NAC necrosis, 182
parameatal-based flap technique, 495–496 surgical techniques, 177–178
postectomy, 497–498 without implants
preputial vertical island flap technique, 496–949 anatomy, 162
Malignant hyperthermia (MH), 80 mammaplast procedures, 161
Mammostat, 201 Periareolar “Round Block” technique (see Periareolar “Round
“Mapping” technique, 147, 148 Block” technique)
Margin Reflex Distance-2 (MRD2), 774 Round Block cerclage stitch, 162
Massive weight loss (MWL) patient safety of breast plastic surgery, 161
abdominoplasty, 423–424 T-inverted techniques, 161
brachioplasty, 428–429 McKissock technique, 215
breast deflation and deformity, 414 Mechanic massotherapy, 1164–1165
breast reshaping, 427–428 Mechanic resurfacing
buttocks deflate and sag, 414 Dermaroller®, 1168
caloric deficiency, 414 inflammatory cascade, 1168, 1169
complications, 430 micro needling, 1169
HCl, 409 Melatonin, 1233–1234
informed consent, abdominoplasty/lower body lift/thighplasty Mentor MemoryGel silicone implants, 310
Index 1267

Metformin, 1232 purse-string suture, 904, 909

Microdermabrasion skin redraping and resection, 905
advantages, 1179–1180 sutures location, 904, 905
mechanism of action, 1180 temporal fascia, 904, 905
microcirculation, 1180 vertical tension, 906
treatment, 1180–1181 vectors, 901, 903
Micro spot technique (MST) vertical-vector face-lift, 909
orbitozygomatic region, 1116, 1118 Minimal gynecomastia, 293
transconjunctival superior and inferior blepharoplasty, 1116, 1118 Minimally invasive approach
Midface rejuvenation CO2 laser associated, 777–779
anatomical issues, 889–890 preoperative evaluation
anesthesia, 891 adipose tissue pseudoherniation, 773
closure, 897–898 distraction test, 774
consultation, selective issue, 890–891 hypertrophic orbicularis oculi muscle, 774
DFF, 889 lid tone, 774
dissection, 894 lower eyelid position, 773–774
fat transfers, 894–895 MRD2, 774
incisions, 893–894 negative vector, 774
SMAS palpebral skin quantity and characteristics, 773
cut edge, 896 pinch test, 774
fat transfers, 894–895 snap test, 774
fixation suture, 896, 897 transconjunctival lower blepharoplasty
PIS suture, 893, 895, 896 anaesthesia, 774
ristow’s space and malar eminence, 896, 897 complications, 777
round drain, 895, 896 preseptal access, 775
surgery, 898 retroseptal access, 775–776
techniques, 898–899 skin treatment, 776
temporal hair, 893 surgical technique, 774–775
temporal region transconjunctival upper blepharoplasty
cephalad and caudal galea, 892, 893 anatomy and surgical technique, 779–780
Daniel soft tissue elevator, 892 contraindications, 778–779
fluted drain, 892 indication, 778
hammock effect, 893 Minor midface retrusion, 18, 21
Sentinel vein and tunnel, 892 Moderate sedation/analgesia, 65
silicone drain, 892, 893 Modern intravenous anaesthesia
temporal fossa, 892 benzodiazepines, 69
temporal lift, 891 blepharoplasty, 72
tension, 892, 893 ketamine, 70
Midfacial Soft (MFS), 796, 797 lifting, 71–72
Minimal access cranial suspension (MACS) lift liposuction, 72
advantages, 909 mastoplasty, 71
antigravitational lifting procedure, 906 morphine, 69–70
complications, 906 opioids, 69
concepts, 901, 903 propofol, 70
contraindications, 903 remifentanil, 70
facial aging factors, 906 rhinoplasty, 71
lateral cheek, flattening of, 903 TIVA/TCI, 70–71
less invasive procedures, 901 Modified Chongchet technique, 832–835
malar fat pad, 903 Moisturization
malar insufficiency, 903 emollients, 1186
nasolabial fold and midfacial hollowing, 903 moisturizer properties and formulations, 1185, 1186
patient selection, 901, 903 physiologic and non-physiologic lipids, 1185
pre-and postoperative treatment, 901, 902, 906–908 soaps and syndets, 1186
primary complaint, middle-aged women, 903 Mondor’s syndrome, 182
principle, 901 Monitored anesthesia care (MAC), 66, 76–77
S-Lift, 901 Monobloc suspension, 877
SMAS, 906 Monolateral cleft
subperiosteal procedures, 909 alar base symmetry, 672
surgical technique alar cartilage, 673
cheek flap, 904 anatomical characteristics, 672–673
classic and extended, 905, 906 bowl grafting, 674
incision, 904 columellar strut, 674
local anesthesia and sedation, 903–904 columella wing correction, 676
midface, 905 incisions and open approach, 673
Penrose drain/suction drain, 906 intranasal route, 673
preoperatively incision lines marking, 903 maxillary osteotomy, 672
1268 Index

Monolateral cleft (cont.) incidence, 800

nasal projection, 672, 673 intraoperative control of hemostasis, 800
nasal tip, 673, 674 management, 801
nasal wing molding, 675 postoperative prevention, 800–801
onlay grafting, 672, 674, 675 preoperative evaluation, 800
septal grafting, 674 Orbitopalpebral region
sheen grafting, 674, 675 adipose body, 736
Z-plasty/V-Y flap, 676 eyeball
Montague’s technique, 499 conjunctival space, 734, 735
Multimodal and preventive analgesia, 87 fascial sheath of the bulb/Tenon’s capsule, 734
Mustardè technique, 826, 827 intermuscular membrane, 735
levator muscle, 735, 736
oblique muscles, 735
N ocular muscles, 734
Narcissistic personality, 29 orbital/arrest tendons, 736
Nasal cleft rectus inferior, 735–736
evaluation, 671–672 rectus muscles, 735
external fctors, 671 superior rectus, 735, 736
septum deviation, 671 eyelids
Tessier classification, 670, 671 adipose compartments, 738
treatment, 672 anatomy, 736, 737
Negative vector, 774 anterior and posterior lamellae, 736
Nesbit’s technique and variations, 498 capsulopalpebral fascia, 739
Nipple-areola complex (NAC), 193–195, 197–203, 207, 208, 210, 216 central/palpebral part, 736–737
Nonphenolic agents ITL, 738
aloe vera, 1198 lateral canthal tendon, 739
azaleic acid, 1198 lateral retinaculum, 739
glabridin, 1197 lower tarsal muscle, 739
glycolic acid, 1198 LPTL, 739
Kojic acid, 1197 medial canthal tendon, 740
licorice extract, 1197 MHSL, 739
melatonin, 1198 post-aponeurotic space, 739
niacinamide, 1198 pretarsal/preseptal part, 737
paper mulberry, 1197 SMAS, 736
retinoids, 1198 subcutaneous layer, 736
soybeans, 1197 superior and inferior tarsus, 738
vitamin C, 1198 surgical topographic anatomy, 740–741
Non-steroidal anti-inflammatory drugs (NSAIDs), 64–65, 85–86 tarsal strap, 740
Nordstrom suture Whitnall’s ligament/superior transverse ligament, 738–739
breast reduction scar, 581 gland and lacrimal apparatus, 741–742
elastic properties, 580 orbit, 733–734
Frechet extender, 577 vascularization (see Vascularization)
galea level, 579 Osteotomy, 694
scalp reduction, 578 Otoplasty
silicone suture, 578 aesthetic deformities, 826
surgical breach, 579 anatomy, ear
tissue defect post excision, 580 anterior/lateral aspect, 823, 824
tissue excision, 580 medial/posterior aspect, 823–825
tissue expanders, 577 muscular structures, 823, 824
neurovascular supply, 825–826
skin and cartilage, 823
O bat ears, 821
Obsessive-compulsive personality, 28–29 cartilage incision, 836
Open rhinoplasty technique cartilage quality, 822
dissection, 636 complications, 836
extra mucosal dissection, 637 cryptotia, 835
indications and contraindications, 636 cup ear, 821, 833, 835
ligamentous support, 637 embryology, ear, 823
nasal tip, 637 hemostasis, 837
septum and hump, 636 history of, 822
transcolumellar incision, 636 informed consent form, 837
Operating room (OR) fires, 80 microtia, 821
Opioids, 86 pavilion malformations, non-operative treatment of, 836
Orbicularis retaining ligament (ORL), 859 preoperative planning, 836
Orbital hemorrhage prominent ears/loop ears, 821, 836
etiology, 800 retro-auricular skin incision, 836
examination, 800 Stahl’s ear/Satyr’s ear, 821, 835
Index 1269

surgical dressing, 837 resection of gland, 165

surgical therapy Round Block cerclage stitch, 167–168
Chongchet technique, 829–830, 832–835 second dermoareolar Round Block, 168
Converse and Wood-Smith technique, 828–831 skin closure, 168–169
Furnas technique, 826–829 triangular vertical skin deepithelialization, 172
Mustardè technique, 826, 827 and vertical skin excision, 172
Scuderi technique, 832 Permanent synthetic fillers
Oxidative stress hydroxyapatite, 1087
BELFAST study, 1216 polyacrylamide, 1087
cellular damage, 1215 polymethylacrylate, 1087
EC-SOD activity, 1216 silicone, 1086–1087
8-hydroxy-2-deoxyguanosine (8-OHdG), 1215 Personal identity
electron transport chain (ETC), 1215 body image, 27
French PAQUID study, 1216 therapeutic failures, 27
GSH-Px activity, 1216 Personality types, aesthetic surgery
post transcriptional regulation, 1216 narcissistic individuals, 29
ROS production, 1216 obsessive-compulsive personality, 28–29
paranoid people, 29
passive-dependent persons, 28
P psychological and clinical theories, 28
PAF. See Platysma auricular fascia (PAF) Phenolic agents
Pain management arbutin, 1197
NSAIDs, 64–65 hydroquinone, 1196–1197
opioids, 64 N-acetyl-4-S-cysteaminylphenol, 1197
preoperative antalgic therapy, 64 Photoaged skin, 1175
Pain physiology, 83–84 Photographic archive handling, 55–56
Paracetamol, 86 Photography, plastic surgery
Paraffin wax angle variations, 51
advertisement, 842, 843 colour temperature, 52
applications, 842 equipment features
complications, 842–844 film and sensor, 48
heater, 842, 843 medical applications, 49
history, 842 professional approach, 50
panacea, 842 reflex and compact digital cameras, 49, 50
syringe, 842, 843 well-shot photograph, 50
Parameatal-based flap technique, 495–496 framing and reference grids, 52–54
Paranoid personality, 29 history and evolution, 47–48
Passive-dependent personality, 28 image and raw file, 51–52
Peer’s cell survival theory of grafted en bloc fat, 147 light exposure, 51–52
Percutaneous collagen induction (PCI) light sources, 50–51
advantages, 1172 medico-legal implications, 55–56
collagen induction, 1168 optimal focusing, diaphragmatic aperture, 51
disadvantages, 1173 structured light scanner setting, 57–59
indications 3D image acquisition system, 56, 57
0.5-mm Dermaroller, 1172 3D image-capturing systems, 56
1.5-mm Dermaroller, 1172 3D reconstruction, 56
MMPs, conversion process, 1168 3D scanners, 56
skin care, 1175 visual representation, 47
Periareolar “Round Block” technique white balance, 51–52
circumvertical technique’s description, 172, 174 Pinch test, 774
complications, 169, 170 The Plaintiff Attorney Viewpoint, 95
cutaneous vascularization, 170 Plastic surgery
glandular reshaping, 172 medical-legal problems
glandular vascularization, 170 communication difficulties, 31
J/T inverted technique, 173 depressive illness, 30–31
marking, periareolar ellipse, 172 distant/unavailable, 33
periareolar skin closure, 173 guaranteeing results, 32–33
scar and areola enlargement, 170 hidden desires, 32
surgical technique hostile patients, 31
areola fixation, dermal window, 166 improper planning, 32
breast lacing, 166–167 indecisive patients, 32
dressing and postoperative care, 169 “Iron Surgeon,” 33
glandular modeling, 165 life crisis, 31
incision and dissection, 164–165 male patients, 31
planning and marking, 163–164 minimal deformity, 30
preparation, 164 patients at risk, 30
regulation of areola projection, 168 payment in advance, 32
1270 Index

Plastic surgery (cont.) red wine, 1220

perfectionistic, 31 skin cancer, 1219
psychotherapy patients, 31 sulforaphane, 1221
secretive/immature patients, 31 Post-aponeurotic space, 739
treatment failure, 33 Postliposuction deformities
unreasonable fees, 33 autologous fat transfer, 389
office risks buttock, lateral and medial thigh, knees, and calves, 398
Agency Law, 92 contour problems, 387
billing, 92 fat grafting, 390–392, 399
ethical and legal issues, 91 indentation and ridge, right upper quadrant, 395
HIPAA and privacy requirements, 92 informed consent, fat transfer procedures
Policy Manual, 91 alternative treatments, 404
Qui-Tam, 92–93 financial responsibilities, 406–407
practices risk factor, 404
administrative coordinator, 38 surgery, 404
business/administrative office, 40 internal ultrasound device, 401
clinical coordinator/registered nurse, 38 linear indentation, right upper quadrant, 394
consultation/physician’s office, 40 liposhifting, 390
costs, surgery, 41 lower abdomen, indentation, 392
credit card authorization, 41, 43 LySonix 2000 cannula, 402
education and training, office personnel, 46 multiple irregular indentations, 402
examination rooms, 40 operative techniques, 390–391
fee worksheet, 40, 41 outcome and complications, 403–404
front office area, 39 patient evaluation, 389
management, 37 postliposuction contour irregularities, 394
office computer system, 46 postoperative compression, 388
office personnel, 37 postoperative oblique view, 393
practice manager, 37–38 preoperative markings, 394
sample patient letter, 45, 46 protuberance and skin discoloration, multiple
surgery scheduling sheet, 42, 44 indentation, 393
telephone, 39–40 second corrective procedure, 400–401
waiting room, 38–39 skin problems, 387
Platelet-rich plasma (PRP), 1084 soft tissue deficiency, 401
Platysma auricular fascia (PAF), 863, 864 suboptimal incision placement, 388
Platysma muscle tumescent technique, 401
anterior section ultrasound, 403
high, 933 waist, lateral thighs, and lateral hip area, 396–397
low, 933 Postoperative nausea and vomiting (PONV), 67, 79–80
muscular incision, 934 Post-operative pain therapy
complete section acute protocols (see Acute post-operative pain management)
anatomical specimen, 934 analgesic therapies, 83
cord-like deformity, 934 multimodal and preventive analgesia, 87
incision, 935 pain physiology, 83–84
indications, 932–933 reflex responses, 83
muscular borders, 936 Power-assisted lipoplasty (PAL), 350–351
net transition, 932 Praffinomas, 842
preoperative, 934 Preputial vertical island flap technique, 496–949
pseudofascial layer, 934 Preventive medicine and healthy longevity
sequence of, 934 aging, biology, 1214
submuscular tunnel creation, 935 Alzheimer’s disease (AD), 1213
lateral section, 929–930, 934 anti-aging strategies, 1217
muscular section, 935–938 antioxidants, 1218–1219
sutures cellular senescence, 1214–1215
anterior (see Anterior sutures) CR, 1218
central sutures, 946–948 hormonal therapy, 1222–1223
lateral (see Lateral sutures) human life expectancy, 1213
latero-medial traction, 936 inflammaging, 1217
medio-lateral traction, 936 maximum life span potential, 1213
traction vectors, 929 nutrition, 1217–1218
undermining, 927–929 oxidative stress, 1215–1216
Poikiloderma of Civatte, 1126 polyphenols, 1219–1221
Polyphenols regular physical activity and exercise, 1221
biotic and abiotic stress, 1219 Proboscis lateralis
curcumin, 1220–1221 clinical presentation and management, 670
experimental and epidemiological studies, 1219 embryogenesis, 669
green tea, 1219 etiology, 669
Index 1271

Profiloplasty report data, 215

dental occlusion, 701–702 suture phases, 217, 218
diagnosis, 701 tailor principle, 215
rigid fixation vertical bipedicle McKissock type, 215
before and after orthodontic treatment and surgery, 708, 709 vertical pedicle technique, 215
before and after triple osteotomy, 708 complications
chin advancement, 704 bleeding and hematoma, 223, 224
complete and radical profiloplasty, 711 infection, 223, 224
exophthalmos, 718 necrosis, 223, 225
facial skeleton, 716–717 nipple-areola complex, 223, 224
“jumping” mentoplasty, 702, 703 pain, 224
long and retroposed chin, 704 pathological scars, 223, 225
long face correction, 713 seroma, 223, 224
mandibular osteotomy, 707–709, 712 unsatisfactory outcome, 223, 225
maxillary osteotomy, 706–709 history of, 193–194
with plates and screws, 703 informed consent, 223–225
profile anomaly, 705 innervation, 197
radiological control, 703 inverted-T scar (see Inverted-T scar reduction
reduction mentoplasty, 710–711 mammoplasty)
rhinoplasty, 702 pedicles, 195
short face operation, 714–715 skin drawing and scar shape, 195–196
soft tissues and skeleton, 701 surgical techniques, 195
surgery, 702 vascularization, 197
Prominent ear, 821 vertical-scar (see Vertical breast reduction)
Psychological stress, aesthetic surgery Reoperative surgery
additive and reductive mammoplasty, 28 aging vectors, 963–964
body image research, 34–35 breast (see Aesthetic breast surgery)
interview studies, 34 complications, 970
measurement techniques, 35 corrugator muscle, 968
organs, body image changes external jugular veins, 968
breast, 28 eyebrow position marking, 968
face, 28 informed consent, 971
nose, 28 neck scars, 970
orthoplasty, 28 patient’s specific activity, 970
personality profile, 35 planned SMAS elevation, 968
preoperative examination, 29–30 postauricular incision, 968, 970
psychoanalytic orientation, 34 preoperative facial analysis, 962–963
rhinoplasty, 28 primary face-lift
standardized testing, 34 ear lobule, skin attachment, 966
Pulse density programme, 1105 helix curve, 964, 965
natural unoperated appearance, 966
non-hair-bearing skin, 964–967
R postauricular area, 966, 967
Rapamycin, 1232 prominent digastric muscles, 967–968
RAW registration technique, 54–55 secondary SMAS flap, 964
Reconstructive and aesthetic surgery tragus, 967
aesthetic operations, craniofacial correction completion, vertical scar, 965
23, 25–26 visible color change, 965, 966
baso cell carcinoma, nose, 18, 20 widened scar, 964, 966, 967
cervical tumour, face lift approach, 18, 19 procerus muscle, 968
complications, 17 secondary face-lift, 961
cranial remodelling, adults, 18, 23, 24 sequential compression stockings, 968
facial asymmetry, moderate orbital dystopia, 18, 22 skin undermining, 968
minor midface retrusion, 18, 21 SMAS flap, 961, 969
training, 17 submental incision, 968–969
Reduction mammoplasty temporal and occipital incisions, 968
breast hypertrophy timing, 968
advantages, 217, 218 wound care instructions, 970
classification, 194–195 Resveratrol, 1233
complications, 218 Retinoids
de-epithelialization, 215–217 adapalene and tazarotene, 1188
glandular and adipose tissue, 217 synthetics, 1187
objectives, 215 types, 1188
pectoralis major muscle, 217, 218 vitamin A activity, 1187
physical symptoms, 193 Retro-orbicularis oculi fat (ROOF), 749, 856, 858
preoperative drawing, 215, 216 Reverse liposuction technique, 147, 148
1272 Index

Rhinoplasty, 622–623 nasal cleft

alar cartilages and resection, 589 evaluation, 671–672
anatomy external fctors, 671
cartilages and ligaments, 595 septum deviation, 671
intermediate crus, 595 Tessier classification, 670, 671
nasal muscles, 596 treatment, 672
nasal valves, 595 nasal deformities, 669
osteocartilaginous structures, 595 nose shape and size, 591
septal cartilage, 594 olfactory mucosa, 597
upper maxillary branch, 594 open rhinoplasty technique
anesthesia, 602 dissection, 636
arhinia, 670 extra mucosal dissection, 637
beauty, concept of indications and contraindications, 636
anatomical subunits, 592 ligamentous support, 637
anthropometric parameters, 592 nasal tip, 637
cephalometric analysis, 592 septum and hump, 636
hemifacies, 592 transcolumellar incision, 636
Leonardo da Vinci’s proportions, 591 outcome and prognosis, 682–684
nasal wings, width, 593 photographs and morphing, 600
nasofacial and nasofrontal angles, 592 physiology, 598
bilateral cleft polyrrhinia, 670
Cronin technique, 677 postoperative care and management, 619, 620
Forked technique, 676, 677 preoperative evaluation
cartilage grafts, 589 instrumental examinations, 599–600
columellar correction medical history and physical examination, 598–599
Blair procedure, 678–679 proboscis lateralis
Brauer-Foerster procedure, 679, 680 clinical presentation and management, 670
Cronin procedure, 679, 680 embryogenesis, 669
Dingman technique, 679 etiology, 669
rectangular flap, 679, 680 psychological implications, 593
complications, 620–621 reductive and augmentation rhinoplasty, 591
craniofacial syndromes, 669 respiratory mucosa, 597
deformity, 677–678 secondary functional rhinoplasty, 677
external valve correction semi-open rhinoplasty technique
alar contralateral cartilage, 678, 679 cartilaginous framework, 637
external nasal vestibule, 678 carti-laginous vault, 636
narinal opening, 678 columellar incision, 636
frontal flap, 586 indications and contraindications, 636
Hindu reconstruction techniques, 585 lateral extremity, lateral crus, 636
informed consent septal deformity correction
characteristics, 600–601 inferior turbinates, 682
edema, 601 internal valve region, 682
intervention, 601 inter-septal-columellar incision, 681
preoperative preparation, 602 intra oral access, 681
lateral and transverse percutaneous osteotomies, 587 mucoperichondrium, 681
manual surgical procedures, 586 oblique incision, 681
medication, 619–620 trans columellar access, 681
mentoplasty augmentation, 588 supernumerary nostrils
monolateral cleft clinical presentation and management, 670
alar base symmetry, 672 embryogenesis, 669
alar cartilage, 673 etiology, 669
anatomical characteristics, 672–673 surgical technique
bowl grafting, 674 access routes and structure exposure techniques, 612–613
columellar strut, 674 alar cartilages, 618–619
columella wing correction, 676 “Butterfly Wings” technique, 615–616
incisions and open approach, 673 endonasal technique, 603
intranasal route, 673 fragmentation, 616
maxillary osteotomy, 672 grafts, 616–618
nasal projection, 672, 673 “Hockey-Stick” resection, 614–615
nasal tip, 673, 674 hump reduction, 606–608
nasal wing molding, 675 intercartilaginous incision, 603
onlay grafting, 672, 674, 675 intranasal access, 603
septal grafting, 674 Joseph’s resection, 614
sheen grafting, 674, 675 Lipsett’s technique, 616
Z-plasty/V-Y flap, 676 nasofrontal angle, treatment of, 608–609
Index 1273

nasolabial angle, treatment of, 609 deficient tip, 648–650, 652

osteotomies, 609–610 definitions, 639
tip surgery, 611 grafts and synthetics
transcartilaginous incision, 604 cartilage, 644, 645
transfixion incision, 604 DCF graft, 644, 646
transmucosal and extramucosal dissection, 604–606 deep temporalis fascia, 644, 645
triangular cartilage, 610–611 fascia, 644, 646
Sushruta Samhita, 586 silicone dorsal nasal sizers, 644, 645
Tagliacozzi technique, 587 overprojected tip, 649
vascularization patient, 639
arterial system, 596 pinched tip/concave rims, 649, 651
lymphatic system, 596–597 short nose
venous system, 596 intercartilaginous graft, 656, 660
Rhytidectomy, 78–79 mucoperichondrium elevation, 656, 659
Rigottomy, 148 pre and postoperative view, 656, 661–662
Rippling, 309–310 rib graft, 656, 662
ROOF. See Retro-orbicularis oculi fat (ROOF) septal extension graft, 656, 660
Rosacea, 1126 upper lateral cartilage and crus, 656, 659
Roux-en-Y gastric bypass (RYGBP), 409 skin, 640
Rubin classification, 1114 soft tissue fillers, 644, 646
suture techniques
concha cymba, 643, 644
S donor cartilage, 643, 644
Scalp reduction 5-0 PDS suture, 643
advantages, 563 suture algorithm, 641
anesthesia, 558 universal horizontal mattress suture, 642–643
benefits, 555–556 thin-skinned tip, 651–653
classic/chronic tissue expansion, 561–562 Selective photothermolysis
disadvantages, 563 dermal heating, 1113
history, 555 epidermolysis, 1113
intraoperative/acute tissue expansion, 562, 563 Semi-open rhinoplasty technique
patient selection, 556 cartilaginous framework, 637
preoperative preparation, 557–558 cartilaginous vault, 636
scalp reduction patterns, 557 columellar incision, 636
stretch-back, 561 indications and contraindications, 636
surgical technique, 559, 561 lateral extremity, lateral crus, 636
timing and operation sequence, 556–557 Septal deformity correction
Unger PATE procedure, 562 inferior turbinates, 682
U-shaped scalp reduction, 560 internal valve region, 682
Y-shaped scalp reduction, 559 inter-septal-columellar incision, 681
Scuderi technique, 832 intra oral access, 681
Secondary breast augmentation. See Breast augmentation mucoperichondrium, 681
Secondary rhinoplasty oblique incision, 681
analysis, 639–640 trans columellar access, 681
autoclavable model, 640, 641 Septoplasty
broad nasal base attic area, 625–626
ala and nostril sil, 663, 664 cartilage and bones, 625
alar axis, 663 Cottle’s magic plane, 627, 629
buccal sulcus incision, 664, 665 endoscopic and video-assisted surgery, 630–632
nasal vault, 664, 665 fourth tunnel, 630
pinch test, 663 hemitransfixion incision, 627, 630
pre and postoperative views, 664–666 inferior tunnels, 629
3-0 nylon interalar suture, 664, 665 left anterior tunnel, 627–628
broad tip problem, 647–648 nasal cavity, anterior half of, 625–626
collapsed nasal bones, 651, 654 nasal valve area, 625–626
crooked nose posterior and inferior chondrotomy, 630
clocking suture, 651, 657 prespinal plane, 629
frenulum suture, 651, 657 subperichondrial-periosteum detachment, 625
longer crus, 651 tunnels connection, 630
multiple scorings, 651, 655 turbinate posterior area, 626–627
nasal bones, 651 vestibular area, 625–626
pre and postoperative view, 656, 658–659 Seroma, 296
septal mucoperichondrium, 651, 655 Severe gynecomastia, 293
upper and lower lateral cartilages, 651, 654 Short-scar breast reduction. See Vertical breast reduction
vertical and horizontal component, 651, 655, 656 “Shutter” system, 1114
1274 Index

Silhouette lift Sub-Auricular Fixation, Extended (SAFE) lift, 877

face Submandibular gland (SMG)
dominant vector, 976 alloplastic materials, 952
indications and contraindications, 977 anatomical structures, 952
liposculpture, 979 anterior approach, 952
marionettes, 977 antero-superior and posterior faces, 952
postoperative results, 976–978 camouflaging technique, 950
pre-operative period, 976–978 cleavage plane, 952
short preauricular scar, 977 commencing resection, 953, 955
straight pilot needle, 976 DTC, 952
surgical incision, 976 gland repositioning, 950
neck intra/extraoral approach, 950
liposculpture, 979 lateral approach, 952
post-operative period, 978 lipofilling, 952
pre-operative period, 978 local myo-adipose flaps, 952
Sirtuin activators, 1232–1233 mandible and cervico-mandibular angle, 953
Skin extension mandibular branches, 950
Frechet’s extensor, 565 mandibular hypoplasia, 952
scalp reduction and positioning platysma identification, 950, 953, 954
complications, 570 preoperative phase, 950
extender size, 567 reduction, 953
factors, 570 short neck, 953, 956
loose scalp, 566 subplatysmal fat, 952
patient selection, 566 tangential plane, 952
preoperative drawing, 567 Sub-orbicularis oculi fat (SOOF), 762, 861
scars, 567 Subplatysmal lipectomy
semi-sitting position, 569 aggressive superficial lipectomy, 948
side effects, 570 angle apex, 948
spatula-shaped instrument, 569, 570 neck, diffuse fat deposits, 950, 951
traction force, 570 submental incision, 948, 949
silicone foil, 565 Suction-assisted lipoplasty (SAL), 349
transposition limbs, median scar removal Superficial muscular aponeurotic system (SMAS), 736
central bald area, 573 aging face, 855, 862, 863
diastasis, 574 face lifting, 852
first flap, 573 high SMAS facelift (see Suprazygomatic techniques)
personal modification, breach balance, 574 MACS lift, 905, 906
preoperative drawing, 571 midface rejuvenation, 889
second flap, 574 cut edge, 896
third flap, 574 fat transfers, 894–895
Skin necrosis, 296–297 fixation suture, 896, 897
Skin needling PIS suture, 893, 895, 896
collagen production, 1170 ristow’s space and malar eminence, 896, 897
directions, 1171 round drain, 895, 896
normal wound healing, 1168, 1169 reoperative surgery, 961, 969
procedure, 1171 Roundblock treatment
Skin pigmentary disorders, 1110 anesthesia, 877
Skin priming, 1097 anterior and inferior portion, 875
SLA. See Supraorbital ligamentous adhesion (SLA) closed RBST, 880–881
SMAS. See Superficial muscular aponeurotic system (SMAS) open RBST, 877–880
SMG. See Submandibular gland (SMG) position/markings, 877
SNAP-25 protein, 1073 superior and posterior portion, 875
Snap test, 774 temporal and mastoid areas, 875
SOOF. See Sub-orbicularis oculi fat (SOOF) skin, ageing necks, 923
Spiral of Tillaux, 735 3D alloplastic volumization, 988
Stavudine, 241 Superior pedicle flaps
Stem cell research, 352 advantages, 197–198
Structured light optical scanning technique contraindications, 198
auto-alignment of images, 59, 60 disadvantages, 198
colour 3D representation, 60 indications, 198
high-intensity light, advantages, 59–60 patient position, 219
image acquisition, 57 postoperative result, 220–222
measurements functions, 58–59 preoperative image, 220–222
surface irregularity measurement, 58 preoperative technique
technical features, 58 adequate blood supply and sufficient venous drainage, 200, 201
3D biometric digital image, 57 breast meridian, 198–199
width and depth measurement, cutaneous ridge, 59 breast rotation, 199, 200
Index 1275

inframammary fold, 198, 199 Silhouette lift (see Silhouette lift)

Keyhole completion, 199, 200 spicules, 975, 976
middle sternal line, 198 static suspension, 980, 981
NAC, 199 thread with spicules, 976
neo-nipple, 199 surgical wounds, 973
patient position, 199 tension, 982
retroareolar tissue removal, 220 tissue suspension, 973
surgical technique Suspension technique
de-epithelialization, 201, 202 complications, 886
dressing, 203 informed consent, 886
inferior portion removal, 201–203 pre-and post operative treatment, 882–885
inframammary fold, 203, 204 rhytidoplasty, 875
intradermal suture, 203, 205 Roundblock SMAS treatment
keyhole margins, 203, 204 anesthesia, 877
pedicle flap technique, 202, 203 anterior and inferior portion, 875
subcutaneous stitches, 203, 205 closed RBST, 880–881
superior flap sculpted, 203, 204 open RBST, 877–880
suture pillers, 203–206 position/markings, 877
vertical pedicle, de-epithelialization of, 219 superior and posterior portion, 875
Supernumerary nostrils, 669–670 temporal and mastoid areas, 875
“Superwet” technique, 79 static suspensions, 875
Supraorbital ligamentous adhesion (SLA), 858 surgical techniques
Suprazygomatic techniques criss-cross technique, 876
cervical branch injury, 916 Duminy and Hudson, 876
complications, 914 Marchac monobloc, 877
facial nerve and branches, 916 SAFE lift, 877
frontal branch injury, 915 Saylan, 876
lipofilling, 917–919 Stocchero RBST open and closed, 876
long-term antigravity, 916 Tonnard and Verpaele MACS lift, 876–877
low SMAS, 915 Van der Lei PRS, 877
patient selection, 911 Virenque, 876
pre-and postoperative, 911–913 Zimman suspension, 877
superficial temporal fascia, 915 Syringe collection method (Khouri), 154
surgical technique Systemic lupus erythematosus (SLE), 242
biplanar flap, 912, 913
elevation, 913, 914
endotracheal anesthesia, 912 T
patient’s skin marking, 912 Tagliacozzi technique, 587
periauricular, retrotragal incisions, 912, 913 Tarsal strap, 740
postoperative period, 914 Tarsal strip (TS) lateral canthoplasty
redraping skin, 913, 914 beady eye appearance, 794
skin dissection, 912–913 tarsal strip procedure, 793
vertical vector, 915 variations, 784, 793
zygomatic arch, 911, 915, 916 Tear trough deformity, 766
Suspension sutures Telangiectasias, 1126
AntiPTOSic, 973 Temporary biological filler
complication, 980–982 collagen, 1085
face anatomy, 974 dextran, 1086
informed consent, 982–984 hyaluronic acid, 1085–1086
knot-free blocking system, 973 injectable agarose gel, 1086
liposculpture, 982 polylactic acid, 1086
local microanatomy, 974 polyvinyl alcohol, 1086
malar region and oral commissure, 982 Tessier classification, 670, 671
musculocutaneous ptosis, 973 Testosterone, 1230
nonabsorbable materials, 973 Thermal relaxation time (TRT), 1123
percutaneous tissue suspension techniques, 973 Thigh dermolipectomy
Prolene mesh, 982 apical and medial flap rotation, 463
resorbent suture, 973 classification, 455–456
special blunt introducer, 982 complications, 467
surgical techniques flaccidity, 453
applications, 975 flap fixing
aptos sutures, 974 antibiotic and fibrinolytic anti-inflammatory therapy, 466
barbed contour threads, 975 and chronology, 454
distal spicules, 975 dermoperiosteal fixation, 464
neocollagen fibers, 975 skin projection, fixing stitches, 463, 465
re-tensioning, 979–980 sulcus skin, 465
1276 Index

Thigh dermolipectomy (cont.) premandible space/lower third aesthetic facial segment,

informed consent 1008, 1012
thigh-lift operation, 468–469 prominent nose and deficient lower third chin-jawline,
vertical scars, 468 1011, 1020
intervention, 453 submandibular augmentation, 1010, 1016
obesity, 458, 460 submandibular implant, 1011, 1018
patient positioning, 457 submandibular zone, 1010
phase lifting, 458, 462–463 unique vertical extension implant, 1010
postoperative care, 466–467 witch’s chin/drooping chin deformity, 1008, 1010, 1011, 1019
preoperative design, 456–457 preoperative planning, patient evaluation, 1024–1025
rhizomelic obesity, 454 regional midfacial volume deficiencies
skin flaps, 454 alloplastic augmentation, 997
subcutaneous tissue, inguinal and gluteal, 462 bony and soft tissue contour, 997, 998
surgical technique, 455 extreme volume deficiency, 997, 1003
tonification/circumferential reduction, 459, 464–465 fat atrophy, 997, 1000
vertical incision, 462 fat grafting, 997
Thigh lift, 319, 321–322 lateral canthopexy techniques, 997
Thorek’s mesogastric excision, 318, 319 long and narrow face, 997, 999
3D alloplastic volumization peri-pyriform implant, 1003, 1007
advantages, 989–990 submalar atrophy, 997, 1002
aesthetic facial surgery, history of, 986–987 suborbital malar extended implant, 997, 1004
beauty, power of, 985–986 subperiosteal upper and midface suspension, 1003, 1005, 1006
chin-jawline augmentation, 1004, 1007, 1008 type 6 midface deficiency, 1003
complications, 1026–1029 type 2 regional aesthetic deficiency, 997, 1001
contouring, 987–989 type 3 regional volume deficiency, 997
cultural variations, 989 uniquely designed suborbital malar implant, 997, 1005
disadvantages, 990 subciliary blepharoplasty approach, 1018, 1021, 1022
facial aesthetics, 987–991 technical elements, 1017–1018, 1021, 1022
history of, 987 Tissue engineering
malar and premandible regions adipose-derived stem/regenerative cells, 1234–1235
aging/recessive inferior orbital rim deficiency, 992, 995 applications, 1233
anatomic zones, 991, 992 autologous fat, 1234
augmentation, 995, 996 fillers and skin, 1249
Contemporary Terino implants, 991, 994 gene therapy, 1234
inherited tendencies, 995 genetic manipulation, 1233
“malar shell” implant, 995 growth factors/hormones, 1233
narrow upper face/long-face syndrome, 991, 993 origin and function, 1233
paranasal area, 991 scaffolds (biomaterials), 1233
submalar triangle, 992, 995 soft tissue augmentation, 1233
zone 1 malar, 990, 992 treatment modalities, 1233
zygomatic arch, 992 TORT/medical malpractice, 90–91
operative technique, 1014, 1017 Tramadol, 86–87
postoperative care, 1026 Transconjunctival approach, 850
premandible augmentation technique Transconjunctival blepharoplasty
central subperiosteal dissection, 1022, 1023 lower
dysesthesias and paresthesias, 1023 anaesthesia, 774
extended alloplastic anatomic-contoured implants, 1023 complications, 777
intraoral routes and extended anatomic chin implants, preseptal access, 775
1021, 1023 retroseptal access, 775–776
intraoral transverse incision, 1022 skin treatment, 776
mandibular angle implant insertion, 1024 surgical technique, 774–775
mental nerve, 1023 upper
midlateral and posterolateral zones, 1021 anatomy and surgical technique, 779–780
posterolateral implants, 1023 contraindications, 778–779
premandible implant, 1022 indication, 778
premandible space Transdermal focused ultrasound (FUS), 517
alloplastic vertical chin lengthening, 1011, 1017 Trendelenburg, Friedrich, 587
boundaries, 1009 Trichloroacetic acid (TCA), 1102
3-cm intraoral incision, 1009, 1014 Tridimensional liposculpture
extended anatomic chin implant, 1008, 1011 abdomen, 370, 372
functional anatomic zones, 1008, 1010 abdominal liposuction, 372
Jawline enhancement, 1008, 1010, 1013, 1015 anatomical and technical considerations, 362–363
marionette groove/anterior mandibular sulcus, 1008 arms, 370
nasal contour-volume alterations, 1011 body mass index (BMI), 359
osteotomies, 1010 clinical series, 360–362
oval chin implants, 1008, 1009 complications, 359, 373–374
Index 1277

first medical examination, 358–359 Turbinate hypertrophy, 694

Gasparotti G point, 365 Turbinate surgery
indications, 357–358 clinical evidence, 633
neck, 372–373 lamina propria, 632
patient physical conditions, 359 nasal fossae, 632
patient selection and clinical evaluation, 363–364 respiratory epithelium cilia, 632
philosophy, 359–360 secretion-vasomotor function, 633
physiological consequences, 359 surgical decongestion, 633
preoperative markings, 364–365 turbinoplasty, 633
surgical technique volume reduction, radiofrequency, 633–634
banana deformity, 366 Twisted nose
concavities and convexities, 368 acute, 688–689
gluteal fallout, 369 analysis
gluteal rejuvenation, 366 age, 689
“small cap maneuver,” 366, 367 basal view, 689
suprapubic and inguinal area, 368 eyebrow-tip-line, 689
Tensoplast and Reston, 367, 368 facial asymmetry, 689
two longitudinal 3 mm-long incision, 365 lateral view, 689–690
torso, 369–370 midline, face, 689
Trunk and extremity contouring photographic documentation, 689
abdominoplasty complications, 695
Beck’s technique, 315, 316 deviated nose, bulbous tip and nasal obstruction, 695, 697–698
Callia’s transverse-inguinal-pubic incision, 317, 318 etiology, 687–688
Castaňares” mixed technique, 318, 319 extremely deviated nasal deformity, 695–697
Demars and Marx’s technique, 315, 316 history, 687
French-bikini like incision, 317, 318 internal examination, 690
Frist’s technique, 315, 317 operative techniques
Kelly’s technique, 315, 316 dorsal hump resection, 691
Thorek’s mesogastric excision, 318, 319 extracorporeal septoplasty, 692–694
vertical excision, 318, 319 Killian procedure, 691–692
brachioplasty nasal tip corection, 694–695
fusiform excision, 318, 320 osteotomy, 694
Pitanguy elliptic axillary excision, 318, 320 partial replantation, 692
with “T” closure, 318, 320 rotatable septal suction elevator, 690, 691
W-plasty, 319 septal cartilage, 691, 692
thigh lift, 319, 321–322 SMAS, 690
Tuberous breast turbinate hypertrophy, 694
anatomical pathology, 260, 262–263, 268, 272 palpation, 690
asymmetric septal deviation classification, 690
ASSGR, 271 settled twisted nose, 689
cranialized IMF and dive-like ptosis, 276 Type I tuberous breast
fourth dimension, 271 graphic sequence, 270
graphic sequence, 277 intraoperative sequence, 268–269
inferior pole constriction, 276 postoperative result, 271
intraoperative sequence and graphic correction, 273–275 severe tuberous deformity, 268
patient position, 277 variants of
postoperative result, 278 cutaneous markings, 278
preoperative planning, 272–273 graphic sequence, 280
shape and volume asymmetry, 276 intraoperative sequence, 279–280
bilateral and symmetric postoperative result, 281–282
graphic sequence, correction flap, 263–264
intraoperative sequence, 264–265
postoperative result, 265–267 U
classification Udall’s technique, 499
type I, 261 Ulnar neuropathy, 239
type II, 261–262, 272–275 Ultrasound-assisted lipoplasty (UAL), 349
type III, 262, 272, 276 Upper eyelid blepharoplasty
clinical evaluation, 260 complications, 751
complications, 282–283 intraoperative adjustment of markings, 749, 750
disadvantages and limitations, 283 male vs. female, 747
embryology, 260 medial fat, 748, 749
malformations, 259 normal anatomy, 748, 749
postoperative failure, 282–283 patient markings, 748, 749
psychological evaluation, 260 pre and postoperative results, 750
surgical failures, 282 preoperative evaluation and consultation, 748
type I ( Type I tuberous breast) without browlifting, 750–751
1278
V lateral/medial pedicle, 228, 231
Vaporization, 1113
Vascularization, 327–328
arteries
collateral branches, 742–743
terminal branches, 743
innervations
extrinsic muscles, 745
motor, 746
ophthalmic nerve, 744–745
optic nerve, 744
sensory innervation, 746
veins
central retinal vein, 744
inferior ophthalmic vein, 743
superior ophthalmic vein, 743
VASER-assisted lipoplasty (VAL), 349
Vector analysis, 788, 789
Vertical breast reduction
complications
hematoma, 236
infection, 237
liponecrosis, 237
long vertical scar, 237
NAC necrosis, 236–237
seromas, 236
shape deformities, 237
crescentic resection, 228, 231
evolution of, 227–228
Hidalgo’s approach, 228
informed consent, 237
inverted-T closure, 232
Index
liposuction, 227, 232
L/J closure, 232
mammaplasty, 228, 233
markings, 228, 229
moderate hypertrophy/ptosis, 228, 230–231
postoperative care, 232
septum-based lateral pedicle, 228, 231, 235, 236
septum-based medial pedicle, 229, 231, 235, 236
superior pedicle, 228, 230–231
vertical closure pattern, 231
Wuringer’s septum, 228, 232
Vertical distraction test, 788
Vertical mastopexy technique, 248, 250, 251
Vertical spacer graft (VSG), 794, 795, 797
Vessel preservation, 318
Vibration Amplification of Sound Energy at Resonance (VASER), 349
Visual analogue scale (VAS), 85
W
Wound dehiscence, 296–297
Wrinkling, 309–310
Y
Yachia’s technique, 499
Yellow peel (YP), 1101
Z
Zygomaticus major muscle (ZMM), 894